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 injection 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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Limitations of Treatment using Dental concentrations of Oxygen/Ozone for the Treatment of the Head,
Neck, Face, Teeth, and Associated Structures:
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I understand with any treatment, there is no guarantee that I will obtain satisfactory results. I may
achieve no results, satisfactory results, or unsatisfactory results. If I am currently under the care of a
physician or dentist for a known or unknown condition(s), it is my responsibility to inform all
practitioners that are providing treatment(s) for my condition(s), of ALL other courses of treatment that I
am receiving. Dr. Azouz has advised me that it is in my best interest to integrate all therapeutic modalities
that are available to treat my health condition(s).
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I understand that Dr. Azouz is not my primary care physician. I understand that it is in my best interest to
have a primary care physician advise me in regard to any treatment(s) that I may choose to receive.
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INFORMED CONSENT TO RECEIVE TREATMENT WITH DENTAL OXYGEN/OZONE
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I hereby authorize treatment with dental oxygen/ozone and certify that I understand the nature of this
treatment, including risks of possible complications and other choices that may be available. I have had
any questions concerning this type of treatment answered. I consider myself to be as completely
informed as possible and hereby consent to treatment using dental oxygen/ozone. I represent that I am
seeking treatment in order to further my own health and for no other reason. I do not represent a third
party. I am aware that I may withdraw this consent at any time.
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Rationale for treatment using dental oxygen/ozone
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Dental oxygen/ozone has been shown to be an effective anti-bacterial, anti-fungal and anti-viral
treatment agent. It increases circulation and oxygenation to the treatment area. It increases the immune
response and creates an environment for the production of anti-oxidants.
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Additional information and explanation for patients:
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Your disorder(s) may not respond to the treatment(s).
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You may experience pain, discomfort, soreness and bruising at and around the site of the injection.
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Transient small “bubble-like blisters” may occur at or around the site of the injection.
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All medications and treatments have some risk of allergic reaction(s). This is an unusual event and is
usually restricted to the local area of the injection site.
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The most common side effect of dental oxygen/ozone treatment is a warm to burning or stinging
sensation at the injection site.
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This treatment of your head, neck, face, teeth, and associated structures, will on occasion
produce flu-like symptoms, which last on average 2-5 days.
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Any new treatment technique may produce unanticipated effects. All known effects to date have
been explained in this document. If you experience any reaction not described in this document, please
contact Dr. Darryl Azouz and/or his staff. The office phone number is: 916-961-2020.
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You will be notified of any significant new findings, which are relevant to your treatment.
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Be informed of the nature and purpose of the experimental procedure.
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Be given an explanation of the protocol to be followed in the medical/dental experimental procedure
and information on the substance or device being evaluated.
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Be given a description of any attendant discomforts and risks to be reasonably expected from the
experimental procedure, when applicable.
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Be given a disclosure of any appropriate alternative procedures, substances, drugs or devices that
might be advantageous to the subject, and their relative risks and benefits, if known.
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Be given an explanation of any benefits to the subject to be reasonably expected from the
experimental procedure, if applicable.
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Be informed of the courses of medical/dental treatment, if any, available to the subject after the
experimental trial if complications should occur.
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Be given the opportunity to ask any questions concerning the experimental trial or other associated
procedures.
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Be instructed that consent to participate in the medical/dental experimental procedure may be
withdrawn at any time, and that the subject may discontinue participating in the medical/dental
experiment without prejudice.
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Be given a copy of the signed and dated written consent form when one is required.
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Be given the opportunity to decide to consent or not to consent to a medical/dental experimental
procedure without the intervention of any element of force, fraud, coercion, or undue influence on the
subject’s decision.
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