INFORMATION, INSTRUCTIONS & CONSENT FOR INTRAVENOUS SEDATION

Date of Surgery *

Select Time *

Dental Practice *

Title *

Surname *

First Name *

Date of Birth *

Please follow the date format DD/MM/YYYY

Select Gender *

Address *

Suburb *

Postcode *

Mobile Number *

Phone Number

Work Number

Email *

(To receive your invoice/receipt and any correspondence from us)

No Medicare Card / International Resident If medicare card number is not provided we cannot lodge your rebate claim.

Medicare Number *

Reference *

The number next to your name

Valid To *

Height

Weight

Have you had previous anaesthetic?

Current Medical Conditions

No Current Medical Conditions.

Asthma.

Reflux.

Diabetes.

Breathing Problems.

Heart Problems.

Any other medical problems

Current Medications

No taking any Medications

Medication Name	Strength (mgs/mcg)	Tablets Per Day	Time (Morning, Midday, Dinner, Before Bed)	Used To Treat

Add More

Allergies

No Known Allergies

List any type of allergies you have

Do you Smoke or Vape?

Do you drink alcohol?

Do you use recreational drugs?

After Surgery

Carers Full Name *

Adult who will pick you up after your surgery, drive you home and care for you over night

Carers Mobile Number *

Carers relation to you *

Next of Kin Full Name *

Contact person in case of an emergency

Contact Number *

Next of Kin relation to you *

GP Name & Medical Center *

If further medical information is required your GP will be contacted, please advise if you do not consent to this

GP Contact Number *

Information and Instructions

Before Surgery

You MUST fast for 6 hours before your sedation appointment to ensure an empty stomach. Strictly no food or drinks (including milk, gum or lollies).
During this 6 hour fasting period you can only drink WATER. However, you must stop drinking water 2 hours before your sedation appointment.
Take your regular medication with a small sip of water the morning of your sedation procedure unless instructed otherwise.
DO NOT drink alcohol or use recreation drugs for at least 48 hours before and after the procedure.
Please wear comfortable loose-fitting clothing and ensure your sleeves can be rolled up past the elbow.
If you have a cold, flu or respiratory infection you must tell us as soon as possible. We may need to re-schedule your procedure to another day.
Please inform us of any changes to your medical history, new medication or allergies prior to your procedure.
You will receive by phone or email your anaesthetic account based on the duration your Dentist requires. This account is payable in full before surgery and can be paid via Bpay or credit card (by phone) only. Any unpaid account may result in your surgery being delayed to another date.
If there is any unforeseen difference to the pre-paid account needed by your Dentist during surgery, for example additional time to complete your treatment, we will advise you after your anaesthetic procedure and payment will be due within 7 days.
You will be contacted to discuss further instructions prior to your procedure, after we receive your completed consent form and confirmation from your Dental Practice. If you wish at any time to discuss your procedure please feel free to contact our office directly.
As your appointment is reserved only for you, we require 72 hours notice to cancel this appointment. A fee of $300 per hour booked will be charged and any amount pre-paid may not be refunded at our discretion.
Any outstanding accounts incurring collection fees will be the full responsibility of the patient/guardian.

After Surgery

After your procedure,you MUST have a responsible adult come to the practice to take you home in a private car, taxi or uber only (not by bus or train) and care for you overnight. Our duty of care means this is not negotiable, if you do not have someone arranged your surgery will be cancelled.
You MUST NOT drive or use potentially harmful equipment for 24 hours after the procedure.
Drink plenty of water after surgery and eat something as soon as you feel comfortable to do so.
Your anaesthetic account is typically entitled to a Medicare rebate, this will be processed after surgery and confirmation via a receipt will be emailed for your records. You can expect your Medicare rebate within 1-3 working days. For a smooth transaction please ensure your details with Medicare including your address and bank account is correct and current by calling 13 20 11.

Intravenous Sedation

Intravenous sedation makes lengthy or complex dental treatment more comfortable. It can help remove anxiety, stress, discomfort, memory and awareness of the procedure. Dr Zonair Ikram is specially equipped and qualified for administering IV sedation and managing sedated patients and medical emergencies.

However as with any anaesthetic procedure, IV sedation is not without risk. These risks include but are not limited to nausea/vomiting, feeling drowsy, small risk of falls, bruising in areas of access to veins, allergic reactions, respiratory depression or a nose bleed. There is an extremely remote risk of serious medical complications.

Consent

I understand my anaesthetic account is prepaid and based on the duration my surgeon needs to carry out my procedure. I will call Dr Ikram's office to arrange payment.

I understand if my Dentist needs more time (not anticipated) during surgery to complete my procedure,I will be notified after surgery and will pay this outstanding account.

Please kindly process my Medicare claim as I have checked all my details are true and correct.

I have carefully read and fully understand this consent form and in addition have had all my questions regarding the sedation to be administered, the outlined risks and side effects answered. I do hereby give my free and voluntary informed consent to the same.