Consent For Intravenous Sedation
接受靜脈注射麻醉手術志願書

I hereby authorize Dr. Edward Tam to perform Intravenous Sedation procedure on me.

I certify and acknowledge that I understand the risks, alternatives and expected effects of the Intravenous Sedation procedure and that all of my questions have been answered fully to my satisfaction. I have informed my dentist of any medical conditions or medications I take that might interfere with the procedure.

I have also been given the pre-operative instruction as below and I will comply fully.

本⼈，同意接受施⾏靜脈注射麻醉。本⼈已完全明⽩有關⼿術之性質，效果，風險及可能引致之併發症，譚頌霖牙科醫生已向本⼈解釋清楚。

我已如實告知我的健康狀况及正在服⽤的任何藥物可能會影響⼿術的狀況。我也得到了以下術前指導，我會完全遵守。

• A light meal should be taken about 3 hours before the procedure
  手術前3小時，進食一些簡單及容易消化的食物
• No alcohol should be taken for 24 hours before the procedure
  手術前24小時內，不可飲用含酒精的飲料
• Prescribed medication (by doctors) should be taken as usual unless the dentist has instructed otherwise
  遵照牙科醫生的指引服用手術前所需的藥物
• Do not wear tight clothing
  請勿穿緊身衣服
• Ladies must not wear nail varnish
  請勿塗指甲油
• Flat shoes should be worn as the patient will be unsteady on their feet after the sedation procedure
  病人需穿上平底鞋，以防麻醉藥還未過時，可能有步履不穩的情況
• The patient should have arrangements made for transport back home and MUST have an adult escort for the remainder of the day
  病人需安排一名成年人陪同於手術後返回住所

• The patient must be escorted home by a responsible adult from the dental surgery
  病人必須由一名成年人陪同離開牙科診所
• The patient must not drive or operate machinery / electrical appliances on the day after the procedure
  手術之後當日，病人切記不可操作任何電器或進行駕駛
• Post-operative instructions will be explained and given to the escort
  手術後有關的指引和解釋將會給予擔當護送的成年人
• The patient is advised to go to bed on arriving home as effects of the drug will last for several hours post-operatively
  手術之後病人應回家休息，以防麻醉藥還未消失
• No alcohol should be taken for 24 hours after the procedure
  手術之後24小時內，不可飲用含酒精的飲料
• Avoid signing any documents
  避免簽署任何文件