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The!following!is!provided!to!inform!patients,!or!the!parent/guardian!of!a!patient!under!the!age!of!18!years,!of!the!choices!and! risks! involved! with! having! treatment! under! anesthesia. This! information! is! not! presented! to! make! patients! more!apprehensive,!but!to!enable!them!to!be!better!informed!concerning!their!treatment.!!! I!hereby!authorize!and!request!Dr.!Shawn!Seifikar!to!perform!the!anesthesia!as!previously!explained!to!me,!and!any!other!procedures!deemed!necessary!or!advisable!as!a!corollary!to!the!planned!anesthesia.!!I!consent,!authorize!and!request!the!administration!of!such!anesthetic!or!anesthetics!(local!to!general)!by!any!route!that!is!deemed!suitable!by!the!anesthesiologist,!who!is!an!independent!contractor!and!consultant.!!It!is!the!understanding!of!the!undersigned!that!the!anesthesiologist!will!have!full!charge!of!the!administration!and!maintenance!of!the!anesthesia!and!this!is!an!independent!function!from!the!surgery!and!treatment!planning.!!!

I!understand!that!procedures!not!discussed,!but!deemed!necessary,!may!be!performed.!!Listed!below!are!complications!that!may!be!associated!with!general!anesthesia.!Serious!complications!are!very!rare.!!The!alternative!options!for!some!patients!include!intravenous!conscious!sedation!or!nitrous!oxide/oxygen!sedation!with!local!anesthesia!or!local!anesthesia!alone.!!

Because!multiple!medications!may!cause!drowsiness,!I!have!been!advised!not!to!operate!any!vehicle!or!hazardous!device!for!at!least!24!hours!post!anesthesia.!Parents!are!advised!of!the!necessity!of!direct!adult!supervision!of!the!child!for!24!hours!following!anesthesia!

!Common%Complications%Associated%with%General%Anesthesia%

_____! Pain!and/or!bruising!at!your!intravenous!(IV)!site!_____! Sore!throat!and/or!hoarseness!_____! Muscle!aches!_____! Nausea!and/or!vomiting!

Uncommon%Complications%Associated%with%General%Anesthesia%_____! Headache!_____! Injuries!to!lip!or!teeth!from!airway!instruments!and/or!devices!_____! Unexpected!drug!reaction!_____! Infection!at!intravenous!site!and!veins!nearby!_____! Bleeding/Injury!to!nose!due!to!passage!of!tubes!_____! Lung!Infection!_____! Weakness!in!breathing!after!awakening!_____! Nerve!damage!

Rare%Complications%Associated%with%General%Anesthesia%_____! Heart!injury!due!to!unexpected!anesthetic!reaction!_____! Brain!damage!or!death!!I!understand!that!anesthetics,!medications,!and!drugs!may!be!harmful!to!the!unborn!child!and!may!cause!birth!defects!or!spontaneous!abortion.!!Recognizing!these!risks,!I!accept!full!responsibility!for!informing!the!anesthesiologist!of!the!possibility!of!being!pregnant!or!confirmed!pregnancy!with!the!understanding!that!this!will!necessitate!the!postponement!of!the!anesthesia.!For!the!same!reason,!I!understand!that!I!must!inform!Dr.!Seifikar!if!I!am!a!nursing!mother.!!I!have!been!fully!advised!of!and!accept!the!possible!risks!and!dangers!of!anesthesia.!I!also!completely!understand!the!alternatives!to!Sedation!and!General!Anesthesia.!I!acknowledge!the!receipt!of!and!understand!both!the!preWoperative!and!postWoperative!anesthesia!instructions.!It!has!been!explained!to!me!and!I!understand!that!there!is!no!warranty!or!guarantee!as!to!any!result!and/or!cure.!I!have!had!the!opportunity!to!ask!questions!about!my!or!my!child’s!anesthesia!and!I!am!satisfied!with!the!information!provided!to!me.!!

!I!have!been!advised!to!look!over!the!pre!&!post!anesthesia!instructions!online!at!www.Daonthego.com!and!have!done!so.!!Signed__________________________________________________!Print!Name________________________________________!!Witness________________________________________________!Date________________________________________________!

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PRE-ANESTHESTIC INSTRUCTIONS

These instructions must be read and strictly followed before commencing with sedation or general anesthesia. Failure or neglecting these instructions could result in aspiration and may be fatal. EATING & DRINKING: Under the age of 5: No solid foods for 6 hours prior to appointment. Breastfeeding should be stopped 6 hours prior to appointment Water or apple juice ONLY may be taken up to 3 hours prior to appointment. NO MILK or other dairy drinks may be consumed! Age 5 and older: No solid foods for 8 hours prior to appointment. Water or apple juice ONLY may be taken up to 3 hours prior to appointment. NO MILK or other dairy drinks may be consumed! Nothing may be taken for 3 hours prior to appointment.

CHANGES IN HEALTH A change in health, especially the development of a cold or fever with congestion of the nose and/or chest is very important. Congestion of the nose and/or chest may compromise the airway. Please notify Dr. Seifikar and your dentist of any change in the patient’s health. It may be necessary to reschedule the appointment. DESIGNATE A DRIVER A responsible adult must accompany and provide transportation home after the procedure. It is recommended that they remain in the office during the procedures. Arrange to have a responsible adult with the patient until the next day to provide care as needed. STREET DRUGS The use of street drugs (marijuana, cocaine, heroin, etc.) is strictly forbidden for several weeks prior to anesthesia and until full recovery is achieved. Literature has reported serious and potentially lethal complications when street drugs and anesthetic agents are mixed.

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THE DAY OF SURGERY CLOTHING Please wear short sleeves, flat shoes and warm comfortable pants. Do not wear nail polish or excessive make up. No contact lenses. Please have your child in comfortable, loose fitting clothes and bring a change of clothing, a pillow and a small blanket for the ride home.

MEDICATIONS Take all regular medications as prescribed with a small sip of water. If any medications require being taken with food, please inform our office. If you or your child has ASTHMA or other breathing problems, please inform our office to discuss our pre-treatment regimen. If you or your child has DIABETES and is INSULIN dependent, please inform our office to discuss our pre-treatment regimen. ARRIVAL Please arrive at your dentist’s office at least 20 minutes prior to the appointment. This will allow you time to use the restroom prior to sedation and treatment. AT THE OFFICE After a brief examination in the dentist’s office, an intravenous line will be started. An uncooperative child will be given an injection in the arm or leg that will render them sleepy and cooperative for the placement of the I.V. Medications will be given via the I.V.. For the optimal safety of the all patients, state of the art monitors will be placed to continuously evaluate the status of the heart and lungs from the beginning of treatment until recovered for discharge. Each anesthetic is individualized for the specific patient, medications administered, dosages and recovery times vary. LEAVING THE OFFICE Due to the lingering effects of anesthesia, a patient must have a responsible adult to accompany them to their overnight destination. A patient will not be allowed to leave the office by taxi or bus without a responsible adult.

IF YOU HAVE ANY QUESTIONS, CALL DR. SEIFIKAR @ 972-591-3355

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POST- ANESTHESIA INSTRUCTIONS

EATING AND DRINKING As soon as the patient is able, encourage fluid intake beginning with clear liquids (water, Gatorade, soda, fruit juice and popsicles) and advance as tolerated to a regular diet. Encourage as much liquid intake as tolerated to reduce the occurrence of nausea and/or vomiting, a common side effect of anesthesia. If vomiting occurs, do not become alarmed, as this is normal. Wait 1 hour to let the stomach calm down before trying again with water. Keep all liquids and food at room temperature. Hot liquid and food may cause bleeding; cold items may not be tolerated due to pain, but will be helpful if swelling is expected. The patient should not be allowed to sleep for prolonged periods of time without urinating. For adults: NO ALCOHOL and NO SMOKING for the first 24 hours.

ACTIVITY The patient must not drive or engage in moderate to high physical activity for 24 hours or until the effects of the anesthesia have subsided completely. Do not plan to drive a vehicle or operate potentially dangerous equipment for 24 hours after anesthesia. Judgment may be impaired during this time as well, the patient should not be allowed to make any critical decisions until fully recovered from the anesthesia. For children, DO NOT allow them to swim, bike ride, or play with other children until the next day. Children will need to be observed closely.

SLEEPINESS The patient may be sleepy for a time after anesthesia. The duration of drowsiness varies with the depth of the anesthesia and the duration of the treatment. To avoid falling off a bed or sofa, you may want to place a blanket on the floor and allow the patient to sleep there. All post-operative patients should sleep on their side supported by a pillow behind their back. This will help to maintain an adequate airway during sleep and if vomiting occurs. The patient’s chin should be an extended position away from the chest. This will also aid in keeping the airway open and facilitate effortless breathing. A responsible adult should arouse the patient every 1-2 hours for the first 4-6 hours after anesthesia to ensure a smooth recovery.

PAIN OR FEVER Muscle aches and or sore throat may occur (similar to the flu) after general anesthesia, but will disappear within 24-36 hours. Drugs such a Tylenol and Advil are usually very effective and should be taken at the first sign on pain, if normally tolerated. (Do Not Use Aspirin!) Children may develop a fever of up to 101 degrees Fahrenheit for the first 12 hours. Tylenol elixir every 3 to 4 hours with plenty of liquids will tend to alleviate this condition as well as treat any post-operative discomfort.

EVENING PHONE NUMBER Be sure to provide Dr. Seifikar with a phone number where he can reach the patient and care provider later that day to check on the progress of recovery and to answer any questions you may have.

SEEK ADVICE: If vomiting persists beyond 4 hours, or temperature remains over 101 degrees Fahrenheit for more than 24 hours, or if you have any other concerns contact Dr. Seifikar @ 972-591-3355.

IF THE PATIENT BECOMES UNRESPONSIVE OR HAS DIFFICULTY BREATHING CALL 911 IMMEDIATELY!