Sedation In Dental Practice printable pdf download

Sedation In Dental Practice

Dr. Martin R. Gillis, Registrar

Sed. Form 1-A

Provincial Dental Board of Nova Scotia

Suite 102, 1559 Brunswick Street

Halifax, Nova Scotia

B3J 1G1

SEDATION IN DENTAL PRACTICE -

As prescribed in Guidelines For The Use of

Sedation In Dental Practice, January 2010.

Oral administration of a single sedative drug is an accepted treatment modality by virtue

of training/licensure as a dentist and does not require a permit issued by the Provincial

Dental Board of Nova Scotia. Utilization of conscious sedation techniques beyond a

single sedative drug does require a permit. In either case, please complete and return this

form.

_________________________

Please be advised that I utilize sedation in my dental practice. I use the following

specific sedation protocols:

CONSCIOUS SEDATION:

1. Nitrous Oxide and Oxygen Conscious Sedation

Yes____ No____

2. Combination of Oral Sedation drugs or Nitrous Oxide/

Oxygen with a single Oral Sedative Drug.

Yes____ No____

3. Parenteral Conscious Sedation (intravenous, intramuscular,

subcutaneous, submucosal) single drug

Yes____ No____

I confirm that I meet the appropriate requirements for training, sedation equipment and

drugs for the management of emergencies as outlined in the Guidelines For The Use Of

Sedation In Dental Practice, January 2010.

____________________________________ _______________________________

(Please Print Name)

(Signature)

____________________________________

(Date)

November 13, 2015

Sedation In Dental Practice