This information is being provided so you may make an informed decision concerning the proposed dental treatment for your child. If you have any questions about the benefits and risks of nitrous oxide/oxygen (or any aspect of the treatment plan) after we review this information, please ask and obtain acceptable answers before signing this document.

As pediatric dentists, we are experienced in helping children overcome dental anxiety. While anxiety can be modified by techniques such as distraction and positive reinforcement, in some instances the use of nitrous oxide/oxygen may be beneficial.

The American Academy of Pediatric Dentistry recognizes nitrous oxide/oxygen as a safe and effective technique to reduce anxiety and enhance communication between the patient and the dental team. Nitrous oxide is a very safe medication that on rare occasion may cause nausea.

I have read and understand this form, and had ample opportunity to discuss the use of nitrous oxide, the risks/benefits/ and alternatives available. All my questions have been answered and I realize I can always seek further information.

I give consent for the patient listed above to receive dental treatment with nitrous oxide.