Click on Calendar, type the year 'YYYY' and pick the month & date.
Sacramento Natural Dentistry


  First name

  Mid Initial

  Last name

Consent For Biopsy

Biopsy specimens are recommended from each cavitation and extraction site. These specimens may be submitted for either pathology reports, or toxicology reports, depending on which report the doctor feels is most beneficial.
Due primarily to financial reasons, we understand that some patients do not wish to have biopsy specimens submitted from each surgical area.
Please Check One:
I, the undersigned wish to have every surgical site or extracted tooth submitted for a pathology or toxicology report.
I, the undersigned wish to have Dr. Azouz submit only those specimens which he feels are absolutely necessary for diagnostic purposes.
I, the undersigned DO NOT wish to have ANY biopsy performed. I choose this option for financial reasons. I understand this is contrary to Dr. Azouz’s recommendations.

There is a charge from the pathology lab, unless covered by your insurance, typically $150.
*Signature:
Date:
(Your digital signature (full name) is as legally binding as a physical signature.)