Dental Anesthesia Consent Form
Patient Information
Patient Name
Date of Birth
Procedure Information
Procedure Name
Date of Procedure
Anesthesia Type
Local Anesthesia
Nitrous Oxide (Laughing Gas)
Oral Sedation
IV Sedation
General Anesthesia
Consent & Risks
I have been informed of the benefits, alternatives, and risks associated with dental anesthesia, including possible complications.
I had the opportunity to ask questions and they have been answered to my satisfaction.
I consent to the administration of anesthesia as indicated above by the dental team.
Additional Comments or Questions
Patient/Guardian Signature
Date
Dentist Signature
Date