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I,
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do voluntarily, knowingly, and willingly give my consent to the administration of dental oxygen/ozone treatments.
I seek this treatment at my own request.
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I understand that dental oxygen/ozone therapy involves the injection of a mixture of
oxygen and ozone in the form of a gas with or without local anesthetic, into the skin,
mucous membranes, muscles, joints, jawbones, and teeth of the head, neck and associated
structures. Dental oxygen/ozone therapy is defined as the creation of a therapeutic
oxygen rich environment, which induces a multi-factorial positive biochemical and
physiologic change in the affected tissues. Dental oxygen/ozone therapy has the
following dental relevant and useful properties: it kills bacteria, viruses, fungi and
parasites. It is a circulatory stimulant, a wound-cleanser, an accelerant for wound
healing, a hemostatic agent, and an immune activating agent. There may be other effects
that at this time are unknown.
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I understand that I should tell the doctor or staff if I have ever had an allergic reaction to
any anesthetic, particularly dental anesthetics prior to any treatment involving injections
with anesthetics.
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There are potential side effects with all types of dental treatments. Dental oxygen/ozone
therapy carries with it some risk of side effects, such as pain and/or discomfort at the
injections site, soreness and temporary bruising. There may be a red, inflamed, blister
type area at the injection site. This area usually heals in a 1-5 day time period. All types
of medications have some risk of allergic reactions. An allergic reaction to the mixture of
oxygen/ozone would be unusual, and usually restricted to the injection site. The most
common patient comment is that there is a warm to burning sensation at the site of the
injection. Some patients may experience flu-like symptoms for 2 to 3 days following
treatment
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