Sedation for adolescents

Professional Sedationist

Adolescent Patient Medical History & Consent Form - SA Sedation

ADOLESCENT PATIENT MEDICAL HISTORY & CONSENT FORM

PROCEDURAL SEDATION AND ANALGESIA - PATIENTS 12 TO 17 YEARS

Dr. Wicus Nienaber (MBChB) | Practice Nr: 1401777 | SA SEDATION
Tel: +27 71 897 6285 | Email: wicus@sasedation.co.za
14 Terrace Road, Mountain View, Johannesburg 2192

ADOLESCENT PATIENT INFORMATION

Patient's Full Name:

Date of Birth:

Age (years):

Gender:

ID/Passport Number:

School/Grade:

Weight (kg):

Height (cm):

PARENT/LEGAL GUARDIAN INFORMATION

Parent/Guardian Full Name:

Relationship to Patient:

Parent/Guardian ID Number:

Contact Number:

Email Address:

Emergency Contact Name:

Emergency Contact Number:

PROCEDURE DETAILS

Procedure Date:

Procedure Time:

Type of Procedure:

Referring Doctor/Dentist:

MEDICAL HISTORY

Please check all that apply to the patient:

Asthma or breathing problems

Allergies (food, medication, latex)

Heart condition

Seizures or epilepsy

Diabetes

ADHD or behavioral disorders

Anxiety or depression

Previous sedation/anesthesia problems

Bleeding disorders

Autism spectrum disorder

Special needs or disabilities

Other medical conditions

If you checked "Allergies" or "Other", please specify:

Current Medications (including vitamins and supplements):

Previous Surgeries or Hospitalizations:

WHAT IS ADOLESCENT SEDATION?

Procedural sedation for adolescents involves administering carefully calculated sedative medications based on the patient's age, weight, and medical condition. This helps adolescent patients feel relaxed and comfortable during medical or dental procedures.

Important Information for Parents and Patients:

The patient will be drowsy but not unconscious
They can breathe normally on their own
They may need to respond to verbal instructions
Continuous monitoring by qualified medical professionals
Medications are specifically dosed for adolescent patients

SPECIAL CONSIDERATIONS FOR ADOLESCENTS

Adolescents may experience sedation effects differently than adults. Parents should be aware of these normal effects:

Vision Changes

Some patients experience temporary double or blurry vision for up to 6 hours
This is normal and will resolve completely
Patient will need assistance walking and must avoid stairs

Physical Effects

Difficulty with coordination and balance
Possible difficulty urinating for 6-8 hours
Drowsiness lasting longer than expected
Nausea or dizziness when standing

Emotional and Behavioral Responses

Increased emotional sensitivity or mood changes
Temporary confusion or disorientation
Some adolescents become more talkative or quiet than usual
Memory loss of the procedure is normal and expected

Recovery Considerations

No driving (if applicable), sports, or physical activities for 24 hours
No important decisions or exams for 24 hours
Must be supervised by a responsible adult
After dental procedures: watch for lip or tongue biting while numb

RISKS AND COMPLICATIONS

While procedural sedation is generally very safe, no medical procedure is without risk. Parents and patients should understand possible complications:

Common Side Effects (1-10% of patients):

Prolonged drowsiness and fatigue
Nausea and vomiting
Headache
Dizziness or lightheadedness
Temporary memory loss
Mood changes or emotional responses
Sore throat or dry mouth

Uncommon but Serious Risks (Less than 1%):

Respiratory depression requiring oxygen support
Cardiovascular changes (heart rate, blood pressure)
Allergic reactions to medications
Prolonged sedation requiring extended monitoring
Unintended deeper sedation
Aspiration risk

Very Rare but Serious Complications:

Severe allergic reaction (anaphylaxis)
Cardiac or respiratory arrest
Permanent neurological effects
Death (extremely rare but possible)

ALTERNATIVE TREATMENT OPTIONS

The following alternatives to procedural sedation have been discussed:

Local anesthesia only
General anesthesia in a hospital setting
Behavioral management and coping techniques
Postponing treatment until the patient is older
Proceeding without sedation
No treatment at this time

After considering these options, we choose to proceed with procedural sedation.

INFORMED CONSENT FOR ADOLESCENT SEDATION

I understand and acknowledge that:

My child will receive procedural sedation to help them remain comfortable during the medical/dental procedure

The sedation will be administered and monitored by Dr. Wicus Nienaber throughout the procedure

My child will be drowsy but not unconscious and will breathe on their own

Common side effects may include: drowsiness, dizziness, nausea, mood changes, and temporary memory loss

Rare but serious risks include: allergic reactions, breathing difficulties, and cardiovascular complications

My child must fast according to the instructions provided (no food/milk for 6 hours, no clear fluids for 2 hours)

I must remain available by phone during the procedure

My child will need supervision for 24 hours after sedation

My child must not drive (if applicable), swim, operate machinery, or participate in sports for 24 hours

I have disclosed all medical conditions, medications, and previous reactions to sedation/anesthesia

FASTING CONFIRMATION

CRITICAL FOR SAFETY - FASTING REQUIREMENTS:

NO solid foods or milk for 6+ hours before procedure
NO clear fluids for 2+ hours before procedure
Only essential medications with minimal water if approved by Dr. Nienaber

I confirm that my child has followed all fasting requirements as instructed

CONSENT FOR TREATMENT

I give consent for Dr. Wicus Nienaber to administer procedural sedation to my child

I authorize emergency treatment if required for my child's safety

I accept full financial responsibility for the procedure

PARENT/GUARDIAN RESPONSIBILITY DECLARATION

I understand that as the parent/legal guardian, I am responsible for my child's safety and must:

Ensure all pre-sedation instructions are followed exactly
Provide accurate and complete medical information
Remain available during the procedure
Supervise my child for the full 24-hour recovery period
Watch for and report any concerning symptoms immediately
Keep my child away from potentially dangerous activities and areas
Contact Dr. Nienaber immediately if concerned: +27 71 897 6285

I acknowledge that non-compliance with these instructions may adversely affect my child's safety and treatment outcome.

SIGNATURES AND CONSENT

By signing below, I confirm that all information provided is accurate and complete, and I have had all questions answered to my satisfaction.

Parent/Guardian Signature:

Date: Time:

Printed Name of Parent/Guardian:

Relationship to Patient:

ID Number:

Witness Signatures:

Witness Name:

Witness Signature:

PROTECTION OF PERSONAL INFORMATION (POPIA)

I consent to the collection and lawful processing of my child's personal and medical information in accordance with the Protection of Personal Information Act 4 of 2013 (POPIA) for clinical, billing, and legal purposes.

I consent to the processing of personal and health information

COMPULSORY MEDIATION AND ARBITRATION AGREEMENT

The patient agrees that all disputes or complaints arising from this treatment, or any follow up treatment or procedures, including those involving allegations of clinical negligence or dissatisfaction with care, shall be resolved via Mediation and should Mediation fail by means of Arbitration through a recognised arbitration institute in South Africa under South African law.

FORM SUBMISSION INSTRUCTIONS
Email this completed form to: forms@sasedation.co.za
AND copy to your referring practitioner's office
Forms must be received at least 24 hours before the procedure date
For questions: Dr. Nienaber +27 71 897 6285

Page 1 of 1 | Adolescent Sedation Consent Form | SA SEDATION

Statistics

A Few Numbers

Sucess Ratio

Years experience

Types of Sedation

Cases

Get a quotation today

Professional sedation services with advanced TCI technology and comprehensive safety protocols for specialized medical procedures.

Request a quotation