ࡱ> 574g bjbj.. ;LjLjV/////CCC8{Cpdffffff$U ///   X//d d   @yg2noR P0 >4 / D rY : Informed Consent for Nitrous Oxide/Oxygen Sedation I understand that my treatment today will include the procedure of N2O/O2 administration. I, , have been informed of the purpose of the procedure and how it will benefit my treatment. The procedure has been described to me, and I understand how it will be accomplished. I should feel more relaxed and less anxious. I understand that certain risk(s) may be associated with this procedure, such as headache, dizziness, nausea, and vomiting. Some patients at high levels of N2O can experience dreaming and hallucinations. I understand the risk(s) associated with this procedure, and I further understand the risk(s) that may occur if the procedure is not completed. I also realize that my doctor must know if I have taken any type of medication or drugs within the past seventy-two (72) hours because these may cause an adverse reaction when N2O/O2 is administered. I verify that I have told my doctor about any such medications and drugs. I have been informed of the alternatives to N2O/O2 sedation and their associated risks. All of my questions and concerns have been satisfactorily answered and addressed. Therefore, I give my informed consent to the administration of N2O/O2 sedation and agree to hold harmless, release, and indemnify agents, servants, students, and employees of the office/clinic of from any and all causes of action, claims, demands, or liability that may arise out of such treatment on behalf of myself, my heirs, my executors, administrators or assigns; or on behalf of my minor child or children or his/her (their) heirs, executors, administrators or assigns. Signed: Date: Witness: Date:      FILENAME CK-Nitrous Oxide-Oxygen Sedation Informed Consent Form.doc 2345xyz{}z {      F G _ e h8Tpjh8TpU hW) hW) h:hhW) H* hW) >* hW) H* h:hH*h:hhW) h:hh05h:hhW) 5F345z { F G _ gdW) $a$gdW)  hW) hW) h0hihiCJaJmHnHuhW) hiCJaJjhW) hiCJUaJ gdW) 9 0&P1h:p0/ =!"#$% x2&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH DA D Default Paragraph FontRiR  Table Normal4 l4a (k (No List 44 W) Header  !4 @4 W) Footer  !PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V (BO)MBT.$@0H!A>풠Uc-zD[&!rX=}zC0` ި%.]Ssd--7 +fOZեrŵVœ\lji2ZGwm-3˵j7\ Uk5FҨ-:xRkcr3Ϣ+9kji9OP Et-j|#p;E=Ɖ5Z2sgF=8 K}*7c<`*HJTcB<{Jc]\ Ҡk=ti"MGfIw&9ql> $>HmPd{(6%z:"'/f7w0qBcF6f Iöi1(\}B5ҹ~Bcr6I;}mY/lIz1!) ac 1fm ƪN^I77yrJ'd$s<{uC>== Ƌ(uX=WA NC2>GK<(C,ݖm: &-8j^N܀ݑ$4:/x vTu>*ٞn{M.Ǿ0v4<1>&ⶏVn.B>1CḑOk!#;Ҍ}$pQ˙y')fY?u \$/1d8*ZI$G#d\,{uk<$:lWV j^ZơSc*+ESa1똀 k3Ģxzjv3,jZU3@jWu;z \v5i?{8&==ϘNX1?  O4׹ӧCvHa01 %xz24ĥ=m X\(7Xjg !Ӆqd? cG7.`~w*?, 2 nN*"Fz_&n &\ F:l[+%f 0 UX  RX8@0(  B S  ?}334x{  W) 0w`*J:hi8Tpq~2T@@UnknownG.[x Times New Roman5Symbol3. .[x ArialC. Aptos Display3. AptosA$BCambria Math"1hggjF  !x203@P ?02!xxuJ :CK-Nitrous Oxide-Oxygen Sedation Informed Consent Form.doc Cathy KorondiMelanie Henriquez Oh+'0,      $<CK-Nitrous Oxide-Oxygen Sedation Informed Consent Form.docCathy KorondidPart 1 of Job 10, one page, 38 copies requested (collate, staple, three-hole punch for 19 only). Normal.dotmMelanie Henriquez2Microsoft Office Word@@i@no@no ՜.+,0X px  7 Tracey O.ILLINOIS CENTRAL COLLEGE  ;CK-Nitrous Oxide-Oxygen Sedation Informed Consent Form.doc Title  !"#%&'()*+-./01236Root Entry F i2no8Data  1TableWordDocument;SummaryInformation($DocumentSummaryInformation8,CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q