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N20 Consent Form

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N20 Consent Form

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  • GENERAL INFORMATION ABOUT NITROUS OXIDE :
    Commonly referred to as “Laughing Gas,” used to reduce anxiety and assist with relaxation.

    • No preparation needed.
    • Nitrous oxide not only reduces anxiety, but it also has analgesic properties by increasing the threshold of any discomfort.
    • Although it offers only mild pain control, this can be enough for simple non-invasive procedures.
    • Its pain-relieving action can help people who have difficulty getting numb.
    • You remain conscious and able to communicate and respond to instructions.

    WHAT WILL IT FEEL LIKE?:
    • A tingling sensation in the fingers, toes, cheeks, lips, tongue or head area
    • Heavy feelings in the legs followed by a floating feeling
    • A resonating voice with a hypernasal tone
    • A warm or hot feeling in the body with flushing in the face

    ALTHOUGH RARE YOU MAY TEMPORARILY EXPERIENCE:
    • Uncontrollable laughter and/or talking
    • Feelings of nausea and/or vomiting
    • Agitation
    • Sluggishness in motion
    • Slurring of words

    NITROUS OXIDE CANNOT BE USED IF YOU HAVE THE FOLLOWING:
    • Pregnancy
    • Significant lung compromise including pneumothorax, pulmonary embolism, air embolism or other severe lung disease
    • Bowel obstruction
    • Middle ear surgery

    NITROUS OXIDE CAN BE USED BUT WITH CAUTION IF YOU HAVE THE FOLLOWING CONDITIONS:
    • Vitamin B12 deficiency or
    • Folate metabolism problems,
    • History of stroke,
    • Hypotension,
    • Or other cardiac conditions.

    By signing below you are at least 18 years of age and are agreeing to consent of the use of nitrous oxide. You agree that the use of Nitrous Oxide has been fully explained to you. You agree that you have informed Perfect Smiles Dental Professionals of all current and past medical conditions and current medications. You agree that you have been informed of the benefits, risks, potential complications, alternatives and contraindications, and that all of your questions have been answered and you are giving your consent for the administration of Nitrous Oxide for the prescribed dental treatment at Perfect Smiles.
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