IV SEDATION CONSENT FORM

Please read all information carefully before completing the form

1. Educational Information

What is conscious IV sedation?
Conscious IV sedation (also known as twilight sedation) helps you relax, reduce anxiety, and feel drowsy during your procedure. A small IV line is placed in your arm, and sedative and pain-relief medications are administered directly into your bloodstream. Throughout the procedure, you will be monitored and given supplemental oxygen via a nasal cannula.

Who Should Consider IV Sedation?
Clients who are anxious, fearful, or have had unpleasant experiences. Those with a low pain threshold or undergoing lengthy aesthetic procedures. Anyone seeking a calm, comfortable experience throughout their treatment.

What are the benefits?
Helps you feel calm and relaxed. Minimizes pain and improves procedural efficiency. Makes long procedures feel shorter and promotes faster recovery.

What are the risks?
Risks are minimal when performed by qualified anesthetists but may include: Mild bruising, soreness, nausea, dizziness. Allergic reactions or rare complications (anaphylaxis, heart irregularities, etc.).

What are my alternatives?
Local anesthesia: you remain awake but pain-free during the procedure. General anesthesia: performed only in hospital settings for major surgeries.

Before & After Sedation Instructions

Before Sedation Instructions

Responsible adult: You must have a responsible adult to accompany you after your sedation appointment.
Transport: Private car or taxi transport must be organised; patients cannot travel home after sedation via public transport.
Solid food: May be taken up to 6 hours prior to your sedation appointment.
Clear fluids: Between 6 hours and 2 hours prior to your sedation appointment.

*Clear fluids include: clear apple juice, clear cordial, black tea (no milk), black coffee (no milk)

*NOT clear fluids: cloudy apple juice, orange juice, milk-based drinks, jelly

Your appointment may be cancelled if you fail to follow the fasting instructions.
Do not smoke or drink alcohol for at least 24 hours before your appointment.
If you feel unwell, have a cough or runny nose, notify your sedationist as soon as possible.
Remove contact lenses before your appointment and wear regular prescription glasses.
Take any prescription medicines with a small sip of water in the morning as normal, unless otherwise told by your sedationist.
Notify your sedationist if there are any changes to your medications, medical history or general health.
Wear warm comfortable clothing that allows easy access to your arms (e.g. short sleeved t-shirt).
Wear flat-heeled shoes as you will be unsteady on your feet for a couple of hours following the sedation visit.
Remove all makeup, jewellery and nail polish (one finger) before your appointment.

After Sedation Instructions

You will be provided with individual post-operative instructions.
Do not drive a vehicle or operate machinery for at least 24 hours.
Do not make any important decisions or sign any legal documents for at least 24 hours.
Do not consume alcohol or sleeping tablets for 24 hours following sedation as these may interact with sedatives that may still be in your body.
Have a responsible adult accompany you for the next 24 hours.
Be careful with stairs and getting in and out of a car.
Do not drink any hot liquids or eat any solid foods until local anaesthetic has worn off (about 2-3 hours afterwards). Appropriate food and drinks include ice cream, yoghurt, smoothie or other cold drinks.
Take pain relief medication (Panadol and/or Nurofen) before local anaesthetic has worn off.
You will be provided with individual post-operative instructions.

Patient Information Form

Patient Name *

Contact Number *

Relationship to Patient (if not patient)

Notice Required

4. I have been informed and given the opportunity to ask questions regarding

Note: Please tick only the items that apply to you. You are not required to tick all boxes.

I understand the nature of the sedation procedure

I understand the risks and benefits

I understand the alternatives to sedation

I understand the before and after instructions

I have completed my medical history accurately

I have arranged for a responsible adult to accompany me

5. Fasting Information

Stopped solid foods at *

Please select date and time when you stopped

Stopped clear fluids at *

Please select date and time when you stopped

I have fasted appropriately

6. Treatment Options

Doctor Name

Planned Treatment

If the treatment cannot be completed within the allocated time, I would like to: (Choose 1 option)

The remaining treatment to be completed in an additional sedation appointment. Interim measures such as temporary fillings or sutures will be used.

The remaining treatment to be completed under local anaesthetic during the recovery period (you will still be mildly sedated but additional sedatives will not be given).

7. Consent and Signatures

I have discussed with my doctor advantages and disadvantages of each treatment option. I understand this is the appropriate treatment. I hereby give consent for treatment to be performed under intravenous conscious sedation.

Date *

Patient Signature

Clear

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