Consent to Nitrous Oxide Anxiolysis

The indication for the use of Nitrous Oxide is to facilitate safe and effective dentistry by reducing anxiety (anxiolysis) and by reducing discomfort (analgesia).  Nitrous Oxide is a gas used in combination with pure oxygen and administered nasally.  It has a long history of use in dentistry, and has been proven very safe and effective for anxiolysis.

Vital signs (blood pressure, oxygen level, heart rate) are frequently monitored during treatment with a pulse oximeter.

The most common side effects of Nitrous Oxide include drowsiness, dizziness, nausea, vomiting or headache.

I have discussed the risks and benefits of Nitrous Oxide anxiolysis with Dr. Blake and/or his staff, and all my questions concerning the anxiolysis and treatment have been answered.

I consent to the administration of nitrous oxide to myself, or my child, by Dr. Blake and his staff.