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Patient Inform Consent for Anxiolysis Mobile App

The purpose of this mobile app is to provide an opportunity for patients to understand and give permission for anxiolysis when provided along with dental treatment. Topics covered include facts for consideration, alternatives, and risks and limitations. You can easily tailor this app to meet your specific requirements.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Patient Inform Consent for Anxiolysis Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico checkbox

    I understand that the purpose of anxiolysis is to more comfortably receive necessary care.

  • Ico checkbox

    to respond.

  • Ico checkbox

    I understand that anxiolysis will be achieved by the following route - Oral Administration.

  • Ico statictext

    SEE SEDATION APPOINTMENT CHECKLIST FOR TIME A PILL SHOULD BE TAKEN AND AMOUNT OF TIME SEDATION WI...

  • Ico statictext

    I understand that the alternatives to anxiolysis are:

  • Ico checkbox

    No sedation: The necessary procedure is performed under local anesthetic with the patient fully a...

  • Ico checkbox

    Nitrous oxide sedation: Commonly called laughing gas, nitrous oxide provides relaxation but the p...

  • Ico checkbox

    Oral Conscious Sedation: Sedation via pill form that will put the patient in a minimally depresse...

  • Ico checkbox

    Intravenous (I V) Administration: The doctor will inject the sedative in a tube connected to a ve...

  • Ico checkbox

    General Anesthetic: Commonly called deep sedation, a patient under general anesthetic has no awar...

  • Ico statictext

    I understand that there are risks or limitations to all procedures.

  • Ico checkbox

    Inadequate initial dosage may require the patient to undergo the procedure without anxiolysis or ...

  • Ico checkbox

    Atypical reaction to drugs that may require emergency medical attention and/or hospitalization su...

  • Ico checkbox

    Inability to discuss treatment options with the doctor should circumstance require a change in tr...

  • Ico checkbox

    If, during the procedure, a change in treatment is required, I authorize the doctor and the opera...

  • Ico checkbox

    I have had the opportunity to discuss anxiolysis and have my questions answered by qualified pers...

  • Ico checkbox

    I understand that I must notify the doctor if I am pregnant, or if I am lactating.

  • Ico checkbox

    procedure.

  • Ico signature

    I hereby consent to anxiolysis in conjunction with my dental care.

  • ...and More!

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