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Sacramento Natural Dentistry

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Amalgam/Metal Removal Informed Consent

* I understand that the American Dental Association (ADA) maintains that amalgam fillings are safe and appropriate. I understand that my dental insurance may reimburse me at a lower level for non-amalgam fillings.
* I give permission to my dentist, Dr. Darryl Azouz, to remove dental amalgam fillings and other metals from my teeth and replace them with materials that we have chosen. These materials may include: composite resins, composite/porcelain hybrids and porcelain.
* Any questions I have had that were not answered by this information have been subsequently and satisfactorily answered by Dr. Azouz and/or his support team.
They have explained to me that:
1. Although one or more of my subjective or objective signs or symptoms may resemble the signs or symptoms of mercury toxicity, I understand that this does not mean that I am suffering from the effects of mercury toxicity either directly or indirectly.
2. There is no scientific evidence that the removal of any amalgam filling will cure or improve any signs, symptoms, problems or conditions that I may have. I also understand there are no scientific tests which can show that removal of my filling will cure or improve any symptoms I have.
3. Any sign, symptom, problem, or condition that I have outside my mouth may involve a general health or medical question. Dr. Azouz is limiting advice to my mouth, and recommends that I consult a physician for any general health or medical concerns or questions I have. Further, he has not told me or represented to me that replacing my amalgam filling or non-precious metals would have any effect on me at all.

For any material chosen to replace dental amalgam, the advantages and disadvantages of the material chosen have been explained to me, including issues such as possible sensitivity, wear or breakage, galvanism(differing metals), and those regarding longevity.
As might occur with the placement of amalgam, gold, or any material, I understand there are situations beyond Dr. Azouz's control that may necessitate root canal treatment or removal of a tooth despite precautions taken and proper procedures utilized. Consequences of removal of fillings also include, but are not limited to: nerve damage, sensitive teeth, sensitive or receding gums, broken teeth, the necessity for crowns, or the loss of the tooth.
My questions concerning the treatment plan recommended by Dr. Azouz and his team, and I agreed to by me, have been fully answered. I have read this statement and understand if fully. I understand the above and wish to undergo the treatment plan outlined by Dr. Azouz and intend to follow all recommendations to the best of my ability. I am requesting treatment including replacement of my amalgam fillings for the reason(s) checked below:
My physician, Dr. Darryl Azouz has recommended it.
I am concerned about the possible effects of mercury, and do not want amalgam in my mouth any longer.
I want this treatment done for cosmetic reasons.
I want this treatment because my fillings need replacement.

(Your digital signature (full name) is as legally binding as a physical signature.)