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Consent for Treatment Plan (Cookeville)
** Office Use Only **
Patient First Name:
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Patient Last Name:
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DOB
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Nitrous Oxide will be given during your child’s dental treatment today. This method of sedation requires your child have no food or drink two hours prior to being medicated.
Valium: this method of sedation requires your child have no food or drink six hours prior to being medicated.
Demerol, Vistaril and/or Midazolam: this method of sedation requires your child have no food or drink six hours prior to being medicated. Patient has had no food or drink after:
Time:
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Parent/Guardian must be on the premises during this patient’s visit today.
Medical Update
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NO medical changes have occurred with my child since I agreed to the treatment plan.
YES medical changes have occurred with my child since I agreed to the treatment plan.
If so, please explain:
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Staff Initials:
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Parent/Guardian Signature:
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Date
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