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Consent Form

Sei Tu Bella Aesthetics logo

Pronox anesthesia Consent Form

I hereby authorize Sei Tu Bella Aesthetics 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.

*If you have been diagnosed with a severe breathing condition, you should consult your doctor before using Pro-Nox.I understand that some possible side effects of nitrous oxide include: dizziness, nausea, lightheadedness, 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 PRONOX system. They are listed below.


Hypersensitivity to nitrous oxide mixtures
Artificial, traumatic or spontaneous pneumothorax
Air embolism
Middle ear occlusion, ear infection
Eye Surgery with intra-ocular gas injection within
Decompression sickness
Severe abdominal distension secondary to intra-abdominal air / intestinal
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.I understand, agree to the above, and wish to use the PRO-NOX nitrous oxide system during my procedure and consent to theself-administrationn of the gas provided to me by the medical director and their medically trained staff members. the last 6 weeks I understand that the treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume those risks. Prior to receiving treatment, I have been candid in revealing any condition that may have a bearing on this procedure.I consent and authorize Sei Tu Bella Aesthetics , LLC, and it’s affiliates to perform the procedure listed on me. I certify that I have read this entire informed consent and I understand and agree to the information provided in the form. My questions regarding the procedure have been answered satisfactorily. I hereby release Heather Merlo, APRN, FNP-C, Medical Director Dr. Fernando Jara, Sei Tu Bella Aesthetics LLC from all liabilities associated with this procedure. This consent is valid for all of my treatments in the future as well.

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