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Amalgam Consent

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 Amalgam Removal Consent

  • Amalgam/Metal Removal Informed Consent

  • I hereby request that Judson B. Wall, DDS remove my dental amalgam fillings and other metals from my teeth and to replace them with dental materials presently considered to be bio-compatible based on existing scientific research. These materials include posterior composite direct resins, lab indirect resins (crowns, inlays or onlays), and lab indirect ceramics (crowns, inlays or onlays).

    It has been explained to me that although the signs and symptoms of mercury toxicity outlined in the scientific literature may reflect signs or symptoms that I presently have, there is as yet insufficient scientific evidence that removing amalgam fillings from my teeth will cause the cure or amelioration of any health problems or conditions. Furthermore, Dr. Wall has made no representation that replacing my amalgam fillings/metals will affect or cure any specific symptoms or medical problems I may have.

    If a posterior composite resin or a lab indirect restoration is the material chosen to replace dental amalgam, the advantages and disadvantages of the materials chosen have been explained to me, including the fact that there has not been a sufficient number of years of use to scientifically prove its wear characteristics. Accordingly, at this time, it is not known if posterior composites will last as long as dental amalgam and therefore may have to be replaced more frequently than amalgam.

    As might occur with the placement of amalgam, gold, or any other dental material, I understand that there are situations beyond the control of my dentist that may necessitate additonal procedures and/or removal of existing teeth despite precautions taken and proper procedures utilized.

    My questions concerning the treatment plan recommended by Dr. Wall have been answered. I have read this statement and am satisfied that I have been fully informed.

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After submitting, feel free to return to the Patient Forms page. Please note, there are multiple forms for each section.

 

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