13802 W Camino del Sol Suite #101
Sun City West, AZ 85375

(623) 583-0151

Anesthetic Consent Form

By initialing this form, I understand that the administration of Local Anesthetic/Medications from dental treatments can have the following inherent risks that occur very infrequently:

Injury to nerves: This could include injuries causing numbness of the lips, the tongue, any tissues of the month, and/ or cheeks or face. This numbness which could occur may be temporary, lasting a few days, a few weeks or a few months. It could possibly be permanent in extremely infrequent situations.

Unusual reactions to medications given or prescribed: reactions, either mild or severe, may possibly occur from anesthetics or other medications administered or prescribed. Some of the dental anesthetics used containe Epinephrine (a vasoconstrictor). Please let the dental team know if you have ever had a negative reaction to or have a heart condition that would inhibit the use of epinephrine. On occasion, side effects include: tachycardia (elevated heart rate), shaking, tremors, elevated anxiety, and on rare occasion, heart attack.

Please sign here with your mouse