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TRIAZOLAM INFORMATION AND CONSENT FORM
Taking triazolam 1 hour prior to your dental appointment is an excellent way to minimize or eliminate anx- ietythat may be associated with going to the dentist. However, even though it is safe, effective, and wears off rapidly after the dental visit, you should be aware of some important precautions and considerations. 1. This consent form and the dental treatment consent form should be signed before you take the medi- cation. They are invalid if Signed after you take the pills. 2. After you have taken the medication, do not drive. Onset of triazolam occurs within 15 to 30 minutes, and the peak effect occurs between 1 to 2 hours after taking the medication. After that, the effects begin to subside, and most people feel back to normal after 6 to 8 hours. However, for safety reasons and because people react differently, you should not drive or operate machinery the remainder of the day. 3. This medication should not be used if: (a) You are hypersensitive to benzodiazepines (eg, diazepam [Valium), lorazepam [Ativan]). (b) You are pregnant or breastfeeding. (c) You have liver or kidney disease. (d) You are taking nefazodone antidepressant (Serzone, Nefadar), cimetidine (Tagamet, Tagamet HB, Novo-Cimetine, Peptol), or levodopa (Dopar, Larodopa) for Parkinson disease. The follow- ing substances may prolong the effects of triazolam: diphenhydramine (eg, Benadryl), prometha- zine (Phenergan, Promacot, Promethegan), verapamil (Calan, Covera, Isoptin, Verelan), diltiazem (Cardizem, Cartia, Dilacor, Dilt, Diltia, Taztia, Tiazac), erythromycin, HIV drugs indinavir (Crixivan) and nelfinavir (Viracept), and alcohol. There may be unusual and dangerous reactions if you are currently taking illegal drugs. 4. Side effects may include light-headedness, headache, dizziness, visual disturbances, amnesia, and
nausea. In some people, oral triazolam may not work as desired.
5. Patients who smoke are likely to notice a decrease in the medication's ability to achieve desired
results.
6. You should not eat heavily prior to your appointment. You may take the medication with a small
amount of food such as juice or toast. Taking it with too much food can make absorption into your
system unpredictable.
7. Nitrous (laughing gas) may be used in conjunction with triazolam and local anesthetic. 8. On the way home from your appointment, your car seat should be in the reclined position. When at home, lie down with the head slightly elevated. Someone should stay with you for the next several hours because of possible disorientation and injury from falling. I understand these considerations and am willing to abide by the conditions stated above. I have had an opportunity to ask questions and have had them answered to my satisfaction. Patient Name____________________________________________________ _________________________ _ Sig nature of patient ________________________________________________ Date___________

Source: http://linkdentaldenver.com/pdf/Triazolam-Information-and-Consent-Form.pdf