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 medication
Do 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:

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BY SIGNING BELOW, I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENT

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