Instructions for Patients Receiving Nitrous Oxide Sedation 1) Do not wear any facial makeup or nail polish. Wear comfortable, casual and loose-fitted clothing. Wear a short sleeve t-shirt, so we can monitor your blood pressure. * Yes, I have read and acknowledge this No 2) Do not have anything to drink 2 hours prior to the appointment (except: water, apple juice or other clear fluids. Milk and orange juice are considered solid foods) * Yes, I have read and acknowledge this No 3) Do not have anything to eat 8 hours prior to the appointment. * Yes, I have read and acknowledge this No 4) Contact us prior to the appointment if there has been a change in your general health (such as severe cold, flu, fever, COVID-19 etc). * Yes, I have read and acknowledge this No 5) Make a trip to the washroom just prior to being seated. * Yes, I have read and acknowledge this No 6) Do NOT take any other sedatives, calming medications before coming to the appointment. This includes taking medications the night before the appointment. This can greatly interfere with your Nitrous Oxide sedation appointment. * Yes, I have read and acknowledge this No 7) If there are any questions prior to the appointment, do not hesitate to call our office at (289)-447-1680 * Yes, I have read and acknowledge this No Consenting Signature * Patient or Patient's Parent/Guardian Name First Name Last Name Name of Patient Receiving Sedation Treatment If Under 18 Years of Age First Name Last Name Date * MM DD YYYY Thank you!
