Healthcare Entonox Treatment Form

Healthcare Entonox Treatment Form

Patient Information

Date of Birth:   Gender:

Insurance Information

Medical History & Screening

Have you eaten within the last 2 hours? Yes No

Possible pregnancy or breastfeeding: Pregnant Breastfeeding

Contraindications / Cautions (check if present)

Pneumothorax or significant chest injury

Known vitamin B12 deficiency or megaloblastic anemia

Recent middle ear or bowel surgery, or recent intraocular air/gas

Other condition requiring caution (specify below)

Planned Treatment

Procedure / Indication:

Planned Date of Treatment:

Risks, Benefits, and Alternatives

Explanation of Treatment: Entonox (a 50% nitrous oxide/50% oxygen gas mixture) will be administered by trained staff to provide analgesia and anxiolysis during the indicated procedure. Administration will be by a facemask or mouthpiece with continuous monitoring.

Benefits: Entonox may reduce pain, anxiety and the need for stronger systemic analgesics. Its onset and recovery are rapid, allowing ambulatory discharge when criteria are met.

Risks and Potential Complications: Common transient effects include dizziness, nausea, vomiting, lightheadedness, tingling, and disorientation. Rare but serious complications include hypoxia from inadequate oxygen delivery, excessive sedation, aspiration, pneumothorax in patients with certain pulmonary disease, and exacerbation of existing B12 deficiency. There is also a documented risk to fetal development if used in early pregnancy.

Alternatives: Local anesthesia, systemic analgesics, regional blocks, or performing the procedure without sedation are alternative options. Declining Entonox will not jeopardize access to appropriate medical care.

Patient Rights and Consent

I acknowledge that the nature and purpose of Entonox treatment, the expected benefits, material risks, and available alternatives have been explained to me in terms I understand. I have had the opportunity to ask questions and those questions have been answered to my satisfaction.

I understand that I may refuse or withdraw consent at any time prior to or during treatment, and that withdrawal may require immediate cessation of Entonox and alternative pain management will be offered when appropriate.

I consent to the administration of Entonox by qualified clinical staff and to such monitoring as the clinician deems necessary. I authorize the recording of treatment details in my medical record.

Pre-Treatment Checks (to be completed by clinician)

Staff verify patient identity, informed consent, and suitability for Entonox. Confirmed:

Identity confirmed Consent obtained Monitoring equipment ready

Post-Treatment Instructions & Observations

Patient will be observed until alert and stable. Driver restriction: I understand I should not drive or operate heavy machinery for at least 30 minutes after administration or as directed by staff. If symptoms of severe nausea, persistent dizziness, breathing difficulty, chest pain, or loss of consciousness occur I will seek immediate medical attention.

Privacy Acknowledgement

I acknowledge that information about this treatment will be recorded in my medical record and used for my care, billing, and healthcare operations in accordance with applicable privacy practices. I consent to the use and disclosure of my treatment information as required for those purposes.

I acknowledge and consent to the privacy practices described above.

Patient Certification and Consent

By signing below I certify that I am the patient named above or the legal guardian or authorized representative. I certify that I have read or had read to me this form, that my questions have been answered, and that I voluntarily consent to the administration of Entonox as described above.

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