Oral Sedation Please complete the following form to consent to oral sedation. Consent for Oral Sedation Effects and Risks associated with the medication Halcion (Triazolam): Blurred vision, slurred speech, dizziness, unstable walking, amnesia Drowsiness possibly lasting up to 8 hours after taking the medicationDo not take with anti-fungal medications. This can cause prolonged drowsiness Do not take with any other types of sleeping aids Possible nausea and vomiting Oral sedation taken while pregnant or nursing could be harmful or fatal to the unborn/born child I acknowledge and understand the following: The above effects and risks of taking this medication I am not pregnant (to the best of my knowledge) or nursing I am unable to drive to and from my appointment. I am unable to drive for the remainder of the day. I have arranged a responsible family member or friend (no Taxi, Uber, Lyft, etc.) to drive me to and from my appointment. My driver does not need to be present during the entire procedure but will provide a contact telephone number in case of an emergency I am unable to work the same day as my procedure Vital signs will be closely monitored during the procedure; however, any respiratory or cardiovascular complications could result in transportation by ambulance to a nearby hospital Treatment during my procedure may require modification due to existing conditions that are only evident when the surgical site has been exposed. I understand Dr. VanWinkle will treat my dental condition as he deems necessary while I am sedated Post-surgical instructions have been explained to me and will be reviewed with my driver on the day of procedure Directions for taking oral sedation drug: Take with water only 1 hour before your appointment Do not drink caffeine or fruit juices of any type the day of your procedure Do not eat 6 hours prior to your appointment Patient Name(Required) First Last Who are you?(Required) Patient Spouse Parent Guardian Your Name(Required)Since you are not the Patient, please enter your name below. First Last Date(Required)Please enter today's date in mm/dd/yyyy format. Signature(Required)BY SIGNING BELOW, I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENTCommentsThis field is for validation purposes and should be left unchanged.