Bellingham Bay Dental

Dr. Grant McClendon DMD
(triazolam, diazepam, lorazepam, midazolam, or zaleplon with or without hydroxyzine)
[ ADA Code D9248 ]
1. BACKGROUND INFORMATION. This form is designed to provide information regarding the use of oral conscious (minimal or moderate oral) sedation ("OCS") agents (triazolam, diazepam, lorazepam, midazolam, or zaleplon with or without hydroxyzine). We have tried to provide the following information about these agents in "plain English" and your cooperation and understanding of this material are necessary as we strive to achieve the best results for you. OCS of the type produced by these agents has proven to be useful in controlling the fears of many dental patients. The properties of these agents have allowed many patients to receive dental treatment in a safe, relaxed state with a reduction in their level of fear and anxiety. However, your awareness and ability to respond will be decreased. Like all medications, though, there are limitations and risks (which will be discussed below), and the absolute success of treatment with oral sedatives is variable and cannot be guaranteed.
2. CANDIDATES FOR OCS. We endeavor to determine eligibility for treatment with oral sedatives through information gathered during our consultation and screening. While many individuals will qualify for treatment with oral sedatives, not all people are candidates for it. If this situation occurs, the doctor will discuss his/her findings with you, perhaps along with certain other possible treatments or options as appropriate. Women who are pregnant, with the likelihood to become pregnant, or lactating should not use oral sedatives (as it may cause fetal damage) nor should people with a known sensitivity to the benzodiazepine class of medication. Also, patients should not consume alcohol while taking oral sedatives or increase the prescribed dosage. If you have been taking any psychiatric mood-altering drug, have a bowel obstruction, or have any acute respiratory conditions such as cold, flu, or sinus infection, you may not be a good candidate for the use of OCS. Please notify the doctor if you have any of these conditions to discuss other options that may be available.
3. YOUR PROTOCOL FOR THE ADMINISTRATION OF OCS. Any negative reaction should be reported to your treating dentist prior to treatment the next morning A dosage of _________________________ will be taken _________________________ prior to beginning your dental treatment. You will not be allowed to drive to or from your appointment and you must have someone pick you up =, sign out, and accompany you home following your treatment with OCS. This person must be 19 years or older. Due to a possible amnesia effect, you should also arrange to have a trusted friend or loved one with you in the 24 hours after your treatment.
4. ALTERNATIVE OPTIONS. Please note that there are other sedation options available for your procedure including nitrous oxide, which is relaxation gas known as laughing gas, topical anesthetic, which is numbing gel that can be placed in your mouth and give you more comfort, and intravenous sedation, which will provide a sedative through your blood system to achieve sedation. These and other methods can often be a valid alternative to OCS. Other alternatives are to have no treatment performed or no pain medications or sedative agents used. If you have any questions regarding any treatment alternatives, please ask your treating dentist or your treatment consultant.
5. RISKS & INCONVENIENCES. Virtually all forms of medication, including oral sedatives, have some risks and possible side effects. Pain medication or sedative agents can, among other things, alter your judgment and work performance, and you should plan accordingly. With OCS, you may experience relaxation or drowsiness, a reduced sense of fear or anxiety, increased tolerance to discomfort, an altered perception of time, tingling sensations, giddiness or lightheadedness, clumsiness, or unsteadiness, nausea, hallucinations, or dreams. Less common side effects include blurred vision, memory loss (which many people deem desirable for dental treatment), or “rebound insomnia” for several days. Rare side effects include agitation, behavior changes, convulsions, hypotension, skin rash or itching, sore throat, fever, chills, unusual tiredness, increased heart rate, hyperactivity, or weakness may occur. If you experience any unpleasant effects, before or after your procedure, please inform the doctor or assistant as soon as possible. There is also a chance of an allergic reaction to the sedation medication that may include: itching, hives, redness of the skin, swelling or sweating. If you notice any of the symptoms you must contact your dentist or other medical professionals immediately.
6. OTHER PATIENT RESPONSIBILITIES. You agree to keep your follow-up appointments and to follow recommended treatments as well as follow other precautions and recommendations that may be provided as part of your pre-op or post-operative instructions. You will not be able to drive or operate machinery while taking oral sedatives and for 24 hours afterward. Therefore, you will need to have arrangements for someone to drive you to and from your dental appointments while taking oral sedatives.
7. PATIENT QUESTIONS. The patient has the right to be completely informed before they give their consent to a procedure. If you have any questions about the OCS, this form, or any other topic, be sure to discuss this with your treating dentist prior to beginning treatment.
8. UNFORSEEN CIRCUMSTANCES. You may also want to designate in writing a person to make any needed decision regarding your treatment while you are in a sedated state. If you do not designate such a person, you authorize the dental practice doctors to use their professional judgment in making decisions regarding your treatment as the circumstances warrant in fulfilling the health-related, functional, and aesthetic objective set out in your treatment plan and clinical records, including abandoning the original treatment plan if medically/professionally necessary.


I acknowledge that the Bellingham Bay Dental has explained to me in general terms OCSS, the alternatives (including non-use), and the risks and inconveniences. I am aware of the conditions that may preclude the use of OCS and confirm that I do not fall into any of these conditions or categories. I have been given the opportunity to ask any questions and any such questions have been answered or explained to my satisfaction. I authorize Bellingham Bay Dental to use their professional judgment to manage any conditions that might unexpectedly arise during the course of the procedure. By signing below, I acknowledge that I have been given time to read and have read the preceding information in this document. I understand this form and I consent to the administration of OCS.
Patient Name*
MM slash DD slash YYYY


(If patient is under 18 years of age or you are consenting to the care of another)
I have the legal authority to sign this consent on behalf of
Minor Patient's Name
MM slash DD slash YYYY


Please designate below the name and telephone numbers for your designated driver (who must be over 19 years of age
Name of Driver*
This field is for validation purposes and should be left unchanged.