Sedation Consent

Nitrous Oxide Sedation Consent

Background Information for Patients Considering
Nitrous Oxide Sedation:

Before treatment is commenced I would like you to read the following important information. If after reading this information you have any questions in relation to any aspect of your treatment please ask.

What is Nitrous Oxide Sedation:

Nitrous oxide is a colourless, non-irritant gas with a slightly sweet smell. It is widely used as a safe and effective method to control anxiety during dental treatment.
The gas is delivered via a nose mask/piece and the concentration of the gas required will be adjusted to suit your needs.


Nitrous oxide sedation can reduce gag reflexes, reduce anxiety levels and help in comfort during dental procedures.

Possible Risks:

The adverse reactions are not common but you need to be aware of before signing the consent to treatment. The nitrous oxide sedation may able unsuccessful so a general anaesthetic may be necessary. Rarely patients experience nausea, vomiting and may aspirate the vomit. Shivering, hysterical behaviour and or confused behaviour may occur. Very rarely patients can lose consciousness. Pregnant women are not candidates for nitrous oxide sedation. In the advent that any of these adverse reactions occur, trained staff and standard operating procedures are in place that will assist the patent.


A full medical, including medications and previous adverse reactions to medications and dental history must be taken at the first or treatment planning appointment and immediately prior to undertaking this procedure.
Do not consume recreational drugs or drink alcohol for the 24 hours before this procedure.
Do not have any solids and limit liquids for at least two hours before and after the procedure, due to this ensure that particularly before this timeframe you have eaten a light meal.
If you have a cold or blocked nose . Nitrous oxide is administered through a nasal mask. You must be able to breathe through the nose (blocked nasal passages defeat the purpose of using nitrous oxide for relaxation). Call immediately if you have any cold symptoms. A change of appointment may be necessary.
Take all your regular medications on your usual schedule unless advised otherwise by your treating or prescribing doctor.
If you are required to take prophylactic antibiotics before any dental procedure, please take your antibiotics 60 minutes before your appointment with a small sip of water.

For parents /caregivers: Focus only on the positive. Be honest when answering questions. Don’t hide the fact that your child may experience a bit of pain, it's important that if this is happening the doctor knows. During the procedure do not bargain, apologise or tell them that “it won’t hurt” or “its nearly over”. Feel free to leave the room during the procedure if you feel distressed or anxious because your child will pick up on your feelings.

Everyone responses differently. Nitrous Oxide is quickly cleared from the body, usually within 3 to 5 minutes after administration has stopped.
Recovery status will be assessed following the procedure. Only fully recovered individuals can be considered for discharge unaccompanied.
Should any residual symptoms remain, you must be accompanied by a responsible adult, so it is encouraged to allow for this beforehand.
Patients, who have taken oral sedative in conjunction with nitrous oxide sedation must be accompanied by a responsible adult.
For parents /caregivers: Please monitor your child’s behaviour for the next 3-4 hours. Normal behaviour during recovery may vary. Your child may be sleepy/groggy or he/she may be irritated/angry. The behavioural changes will diminish as the mediations wear off. If your child desires to sleep, please allow him/her to rest. Keep activity to a level that does not require coordination.
Absolutely no swimming, bike riding, skate boarding, roller skating, etc. for the remainder of the day. Resume usual activity tomorrow. If your child has had a local anaesthetic as well, they need to be careful not to bite their lip or cheek while it is numb.

Health Funds:
Any quotation includes the Australian Dental Associations scheduled item numbers and tooth identification if applicable. These numbers are recognised by the health funds. I answer to you for the services that I provide and the fees that I charge. That is your right and my responsibility. Your insurer answers to you for the rebates they give. That is your right and their responsibility. It is neither my responsibility nor my right to be involved in that relationship.

Finally if you should have any further queries please do not hesitate to ask.

Consent for Treatment:
Nitrous Oxide Sedation

This is my consent to provide the dental treatment as indicated in this form.

  • I have read any provided ADA handout for this course of treatment.
  • I have received a written or verbal quotation and I am clear on the costs involved in this course of treatment.
  • I have given the practice a full, complete and up to date medical and medications history.
  • I am aware that a specialist referral is available for this procedure
  • I fully understand the entire document and the what the treatment entails including advantages, disadvantages, limitations, risks.
  • The treating dental practitioner has explained the known possible complications of and alternative treatments.
  • The treating dental practitioner has answered all of my questions to my full satisfaction.
  • I understand that the results of the treatment can not be guaranteed.
  • I give my permission and consent for nitrous oxide sedation to be administered.


Sign Here

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