BHD Moderate Sedation Consent

Please complete the form below; for best results use Google Chrome or Mozilla Firefox browsers.

Consent for Dental Treatment with Minimal or Moderate Sedation

Date *

PROCEDURE(S): *

OPERATING DENTIST: *

I, the undersigned, hereby consent to the procedure(s) and anaesthesia noted above. I acknowledge that the procedure(s), its implications and possible complications have been explained to me, along with the alternatives including not having any treatment. I understand that the procedures will require minimal or moderate sedation, and I consent to the administration of this by the above-named practitioner. I also understand that during the course of any treatment, unforeseen circumstances may arise that make it advisable for an additional or alternate procedure to be performed, and I also consent to such reasonable additional or alternate procedures being performed on me.

Patient Signature

Date / Time

I acknowledge receiving a copy of the pre- and post-operative instructions which have been explained to me. I understand all the advice given to me by my dentist. After my discharge, I will notify my dentist if I experience any acute pain, heavy bleeding from the surgical site, respiratory problems, or any other post-operative problems.

Signature

Date / Time

Phone

New To The Clinic ?

Blue Heron Dental Group is built on a strong reputation of over 30 years of service to the Ottawa community and the families who live here. Other dentists in the community refer pediatric patients to our clinic due to our experience and reputation when treating children.

Have A Question? Call Us

Book An Appointment

Quick Links

Home
About Us
Services
Patient Forms
Contact Us
Privacy Policy

Contact Us

102-1500 Bank street Ottawa, Ontario K1H 7Z2

613-706-4101

Info@blueherondentalgroup.ca

Clinic Hours

Mon: 7:30am - 3:30pm
Tue: 7:30am - 3:30pm
Wed: 7:30am - 3:30pm
Thu: 7:30am - 7:30pm
Fri: 7:30am - 3:00pm

Sat: Closed
Sun: Closed

Holiday Hours Click Here