DR. RICKY SEE & ASSOCIATES PEDIATRIC ORAL SEDATION INFORMATION AND CONSENT FORM
Chloral Hydrate and Hydroxyzine(Atarax) are medications that can greatly minimize anxiety that
may be associated with dental treatment. In a relaxed state, your child will usually still be able to communicate with the dentist while treatment is being performed. Even though it is safe, effective, and wears off rapidly after the dental visit, you should be aware of some important precautions and considerations. 1. The onset of Chloral Hydrate and Hydroxyzine are approximately 30 minutes. The peak effect
occurs between 1 to 2 hours. For safety reasons and because people react differently, you child should be watched carefully by a responsible adult for the rest of the day and is not supposed to engage in any potentially dangerous activities until the next day.
2. Medications should not be used if your child is hypersensitive to Chloral Hydrate and/or Hydroxyzine
or if he/she has severe liver or kidney diseases.
3. Side effects may include light-headedness, headache, dizziness, visual disturbances, amnesia, and
nausea. In some people, oral sedation with Chloral Hydrate and Hydroxyzine may not work as desired and I.V. Sedation at a different appointment may be necessary.
4. Your child should not eat anything for six (6) hours before his/her scheduled appointment with the
exception of medications normally taken and medications prescribed by our office. Patients for morning treatment shall have no food or liquid after midnight.
5. Nitrous oxide (laughing gas) and local anesthetics may be used in conjunction with Chloral Hydrate
6. On the way home, your child’s seat in the car should be in the reclined position. When at home, lie
down with his/her head slightly elevated. Someone should stay with him/her for the next several hours because of possible disorientation and possible injury from falling.
I have been fully advised of and accept the possible risks of oral sedation. It has been explained to me and I understand that there is no warranty or guarantee as to any result and/or cure. I have had the opportunity to ask questions and I am satisfied with the information provided to me. I understand all the information above and agree to follow all the instructions given above. I, the undersigned, hereby consent to _________________________________________________________ ( layman descriptions of the procedures to be performed)to be performed on __________________________by Dr. ______________________________ under oral and inhalation sedation. I also consent to such additional or alternative procedures, which the doctors determined to be immediately necessary during the course of the above-described procedures.
Parent/Legal Guardian Signature: ____________________________ Date: _____________________ Witness: ________________________________________ 701 Sheppard Ave. E., Suite 102, Willowdale, Ontario, M2K 2Z3 (416) 222-2192
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Acetaminophen (Tylenol) Acetaminophen reduces fever and relieves pain. Typical uses include fevers, immunizations, teething, earaches, bruises, headaches, etc. Please notify us prior to using Tylenol for babies under 2 months of age. Acetaminophen is available in the following forms: Infant drops (80mg/0.8 ml) Children's liquid (160mg/5ml) Chewable tablets (80mg) Junior