Sedation Information And Consent

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The medications planned for your appointment will create a relaxed, sleepy state while treatment is being performed. Even though it is safe and effective, you should be aware of some important precautions and considerations.
1. Do not drive after taking the first dose of your medications. Patients must be driven to
and from the office by a responsible companion. You should not drive or work or
operate machinery until the day after your appointment for sedation. Avoid stairs
and heavy lifting. Even though you will be able to communicate effectively, you
should not make or be entrusted with decisions or valuables until the day after your
appointment because some people experience varying degrees of amnesia or cloudy
thinking. Those caring for and transporting you should be made aware of this.
2. Sedative medications should not be taken if:
a) You are hypersensitive to benzodiazepines (Valium, Ativan, Versed, etc)
b)You are pregnant or breast feeding
c) You have liver or kidney disease
Take your regular medications unless specified by your physician or dentist.
Do not take over the counter medications prior to or immediately after your
sedation appointment without consulting a doctor. Of course, drinking alcohol or
taking illicit/recreational drugs can also cause dangerous reactions.
3. No food or drinks (except water with meds) 6 hours prior to appointment.
No stimulants (caffeine, etc.) for 12 hours before or after your appointment.
Stimulants can significantly decrease the effectiveness of the sedation
medications. No alcohol until the day after your appointment.
4. Side effects may include (light-headedness, headache, dizziness, visual
disturbances, amnesia, and nausea). In some people, sedatives may not work as
5. Nitrous oxide (laughing gas) may be used with your sedative medication and local
6. Please remove contact lenses prior to appointment.
7. Dr Moussalli may be reached at the OFFICE: Decatur Office Phone Number 269-423-4961, or at
HOME: 269-674-8187, or by CELL: 269-436-0258.
8. On the way home from the dentist, your seat in the car should be in the reclined
position. When at home, lie down with your head slightly elevated. Someone should
stay with you for the next twenty-four hours because of possible disorientation and
amnesia and possible injury from falling.
I understand these considerations and I am willing to abide by the conditions stated
above. I have had an opportunity to ask questions and have had them answered to
my satisfaction.
Signed (patient)___________________________________________ Date_________
Signed (guardian, if pt under 18 years) ________________________ Date_________
Signed (transporting/accompanying companion) ________________ Date_________