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Consent for Anesthesia for Child With Special Needs

Note: This form will not submit successfully unless all the fields have entries.

Patient's Name:    
Date of Birth: Date of Appointment:

The following information is provided to inform you of the choices, risks and benefits involved with having treatment under general anesthesia (this includes sedation- conscious, deep and general anesthesia- asleep, unconscious).

I, , hereby authorize Nova Dental Anesthesia or it agents, to perform the anesthesia procedure as previously explained to me and any other procedure deemed necessary or advisable as an adjunct to the planned anesthetic procedure. I consent to the administration of such anesthetic(s) by any route suitable by the anesthesiologist, who is an independent contractor and consultant. I understand that the anesthesiologist will have full charge of the administration and maintenance of the anesthesia and that this is an independent function from the operation.

I understand that there are potential complications associated with the administration of anesthetic drugs including, but not limited to, pain, hematoma, phlebitis, numbness, swelling, bleeding, bruising, nausea, vomiting and allergic reaction. I further understand that complications may require hospitalization and could result in death.

I understand that anesthetics, medications and other drugs may be harmful to the unborn child and may cause birth defects or spontaneous abortion. Recognizing these risks, I accept full responsibility for informing the anesthesiologist of a suspected or confirmed pregnancy with the understanding that this will result in the postponement of the procedure. For the same reasons, I understand that I must inform the anesthesiologist if I am a nursing mother.

I have been fully advised of the planned anesthetic and accept the potential risks and dangers. I acknowledge that I have had the opportunity to ask questions about my anesthetic and I am satisfied with the information provided to me.


Patient: Date:
For Office Use:
Patient: ____________________________________________ Date: ______________________
Witness: ____________________________________________ Date: ______________________