Pain? Dental Emergency?!
Master, College of Conscious Sedation American Dental Society of Anesthesiology
Advanced Systemic Health Care through the Mouth
All your dental treatment needs met in one location
Michael A. Starkey, DDS MS and The Team
Peri Dental Surgery (Around the time of surgery)
Anesthesia Informed Consent
And Anesthesia Instructions
Sedation Anesthesia Informed Consent
Dr. Starkey and his staff have informed me of the benefits of IV sedation and also the risks and disadvantages. I have read and understand the pre operative peri operative and post operative IV sedation instructions.
I understand that I have to have a ride and an escort and I am to tell the Dr or staff any changes in my health history on the day of surgery. I have been told there is a deposit for IV sedation surgery and that I have to give notification 24 hours to 72 hours ahead of time or lose my deposit.
I understand that Dr. Starkey does not use narcotics in the IV sedation but uses a pain control medication that works well unless I have been taking narcotic pain relievers for a month or longer.
I am to tell Dr or his team that I am taking narcotics regularly and for how long. The reason is so Dr. Starkey does not use a pain medication that causes a reversal of narcotic medications in my system. That results in restless leg syndrome and irritability for several hours.
I do I do NOT take narcotics on regular basis for at least a month.
Dr. needs to know this for my protection and for better visit.
I have been told that IV sedation does NOT always work and Dr. Starkey cannot guarantee that the IV sedation will work.
I understand that Dr. Starkey and his team will be giving me supplemental oxygen and relaxing gas unless relaxing gas bothers me.
I am to tell Dr. Starkey if I do NOT want relaxing gas (nitrous oxide/N2O2)
The following are complications that I acknowledge as possible
Pre-Operative, Peri-Operative, and Post-Operative Instructions for an easier visit and recovery
Before your dental surgery it is important to:
Anesthesia Informed Consent
Dr. Starkey and his team have reviewed risks of local anesthesia and I have decided that local anesthetic with no epinephrine is what I want
I am okay with the Dr. and his staff using lidocaine with epinephrine or similar local anesthetic, I am okay with long acting anesthetic.
Patient to initial or to tell Dr. Starkey or his team the kind of LA and
then circle the type wanted to be used.
Post Sedation Dental recovery
I have read the above risks and Dr and his team have discussed requirements and risks and have answered all my questions. I give Dr. Starkey and his staff to provide me with oral sedation, relaxing gas, and or IV sedation with adjunctive medications that will help with my recovery and surgery.