Nitrous Oxide Consent Form
Complete this form before your nitrous oxide appointment to share your basic details, appointment information, and screening responses.
Patient Details
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Procedure Details
Appointment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Dentist or Clinician/Provider Name
*
Health Screening
Are you currently pregnant or might you be pregnant?
*
No
Yes
Unsure
Prefer not to say
Are you currently taking any medications or supplements that could affect nitrous oxide use?
No current medications or supplements
Prescription medications
Over-the-counter medications
Vitamins or supplements
Herbal products
Prefer not to say
Do you have any allergies or previous adverse reactions relevant to nitrous oxide or similar sedation?
No known allergies or adverse reactions
Allergy to medications
Allergy to latex
Previous reaction to anesthesia or sedation
Breathing-related reaction
Prefer not to say
Have you used alcohol or recreational drugs recently?
*
No
Yes
Unsure
Prefer not to say
Submit Nitrous Oxide Consent Form
Should be Empty: