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Texarkana consent form
I understand that anxiolysis is a drug-induced state of reduced awareness and
decreased ability to respond, that its purpose is to reduce fear and anxiety, that I wil be
able to respond during the procedure, and that my ability to respond normal y returns
when the effects of the sedative wear off.
I understand that the purpose of anxiolysis is to more comfortably receive necessary
care, and anxiolysis is not required to provide the necessary dental care. I understand
that anxiolysis has limitations and risks and absolute success cannot be guaranteed.
I understand that Texarkana Endodontics uses Halcion (triazolam) to provide anxiolysis.
I wil take the medications as prescribed approximately one hour prior to my appointment
I understand that after taking the medication I am not to drive, operate machinery, or
I wil explain to my driver that I wil notify the receptionist at Texarkana Endodontics when
I have arrived so that I may be assisted into the office.
Halcion may cause a patient to forget experiences during and before
medication. I wil not make any important business decisions prior to taking the
I understand that the alternative to anxiolysis in this office is no sedation, and that the
procedure wil be performed using local anesthetic.
I understand that there are risks or limitations to al procedures. For anxiolysis these
Inadequate initial dosage may require the patient to undergo the procedure
without anxiolysis or delay the procedure for another time.
Atypical reaction to drugs which may require emergency medical attention and/or
hospitalization such as altered mental states including aggressiveness
(disinhibition), al ergic reactions, and physical reactions including possible
Inability to discuss treatment options with the doctor should circumstances
If during the procedure a change in treatment is required, I authorize the doctor to make
whatever change he deems in his professional judgment is necessary. I understand that
I have the right to designate the individual who wil make such a decision.
I understand that I wil notify the doctor if I am pregnant, or if I am nursing. Halcion
cannot be used with patients who are pregnant.
I wil inform the doctor if I am hypersensitive to benzodiazepines (Valium, Ativan, Versed,
I wil inform the doctor if I have liver or kidney disease.
I understand that I wil not drive to the appointment while taking the prescribed
medication, and I wil not drive for 24 hours after taking the prescribed medication.
I wil tel the doctor if I am taking the fol owing medications as they can adversely interact
with Halcion (triazolam): nefazidibe (Serzone); cimetidine (Tagamet, Tagamet HB,
Novocimetine or Peptol); levodopa (Dopar or Larodopa) for Parkinson’s disease;
antihistamines (such as Benedryl and Tavist); verapamil (calan); diltiazem (Cardizem);
erythromycin and the azol antimycotics (Nizoral, Biaxin, or Sporanox); HIV medications
indinavir and nelfinovir; and alcohol.
I wil not drink alcohol while under the influence of this medication.
I wil not use this medication for purposes other than anxiolysis during treatment at
I have read and understand these instructions.
Patient (Print): _________________________________________________
Patient (Signature): _____________________________________________
Witness or Guardian: ___________________________________________
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