Consent Form & and Contraindications for Administration of Nitrous Oxide for Pain & Anxiety with the PRO-NOX system during Aesthetic Procedures

I hereby authorize Arsenault Aesthetics providers and staff to provide me with Nitrous Oxide through the PRO-NOX system for the purpose of pain and anxiety control during my procedure.

PRO-NOX is a self-administered (under the supervision of medically trained staff), quick onset, fixed 50% nitrous and 50% oxygen pain management system with short duration of effect. It is generally metabolized and “out of your system” (you are back to normal) within minutes of discontinuing, and therefore you are able to regain complete mental and physical function quickly and drive home.

The risks and benefits of inhaled nitrous oxide for pain and anxiety control have been explained to me as have alternative forms of pain control options. Although no severe complications have been reported with this device and type of analgesia, the risks could include headache, euphoria, decreased mental and physical awareness and control, device malfunction and potential overdose, failure of effect, and other unforeseen problems. We have seldom seen any of these problems but are required to disclose them.

I understand that some possible side effects of nitrous oxide include: dizziness, nausea, light-headedness, and unsteadiness. I understand that I should wait 10 minutes after the last use of nitrous oxide before driving a car or operating any type of machinery.

I understand that using nitrous oxide may make me unsteady and that if need to get off the procedure table, I will do so only with assistance.

I agree to hold the mouthpiece and inhale the nitrous oxide/oxygen gas mix without assistance from others and only as needed through the procedure to maintain my comfort level.

I understand that nitrous oxide has been safely used throughout the world for pain and anxiety management for many decades, and continues to be used worldwide today. I also understand that the risks for nitrous oxide use are the same risks that exist for virtually all other pain-relieving medications that I may choose to use during my procedure.

I understand that there are several contraindications for use of Nitrous Oxide through the PRO-NOX system. They are listed below.

CONTRAINDICATIONS

• Pregnancy
• Hypersensitivity to nitrous oxide mixtures
• Artificial, traumatic or spontaneous pneumothorax
• Air embolism
• Eye Surgery with intra-ocular gas injection within the last 6 weeks
• Decompression sickness
• Severe abdominal distension secondary to intra-abdominal air / intestinal obstruction
• Inability of patient to follow directions
• Inability of patient to hold own delivery device (mouthpiece or mask)

I acknowledge that I do not have any of these conditions and consent to the use of Pro-Nox for my procedure today and in the future.

Your consent and authorization for this elective procedure is strictly voluntary. By signing this informed consent form, you hereby grant authorization to our medical staff to perform and/or to administer any related treatment as may be deemed necessary or advisable in the diagnosis and treatment of your condition.

The nature and purpose of this elective procedure and the complications and side effects have been fully explained to me. Alternative treatments and their risks and benefits have been explained to me and I understand that I have a right to refuse treatment. I agree to adhere to all safety precautions and instructions after the treatment. I have been instructed in and understand post treatment instructions and have been offered a written copy of them. I understand that no refunds will be given for treatments received. No guarantee has been given by anyone as to the results that may be obtained by this treatment.

I have read this informed consent and certify that I understand its contents in full. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I have had enough time to consider the information given me and feel that I am sufficiently advised to consent to this procedure. I accept the risks and complications of the procedure. I certify if any changes occur in my medical history I will notify the office.

I hereby give my voluntary consent to this elective procedure and release the facility, medical staff, and specific technicians from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age and am not under the influence of alcohol or drugs. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns.

I agree, if I should have any questions or concerns regarding my treatment / results I will notify this office at immediately so that timely follow-up and intervention can be provided.