Schedule an Appointment (801) 298-1812

Ozone Consent

  • Ask The Doctor

 Ozone Therapy Consent


  • I do voluntarily, knowingly, and willingly give my consent to the administration of dental oxygen/ozone treatments. I seek this treatment at my own request.

    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.

    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.

    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.

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY

  • Limitations of Treatment using Dental concentrations of Oxygen/Ozone for the Treatment of the Head, Neck, Face, TMJ, Teeth, and Associated Structures:

    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. Wall has advised me that it is in my best interest to integrate all therapeutic modalities that are available to treat my health condition(s).

    I understand that Dr. Wall 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.


    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.
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY

  • Rationale for treatment using dental oxygen/ozone

    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.

  • Witnessing and Signatures:

    I have read the information and consent forms before signing. I understand that oxygen/ozone therapy in medicine has been used in the United States since 1885. This therapy has been grandfathered for medical use prior to the formation of the Food and Drug Administration. The FDA has not reviewed or approved of statements made in this informed consent. Results may vary. No claims are made regarding the application of any particular therapy using any particular products for any particular reason. I have been offered ample opportunity to ask questions and have received answers that are to my complete satisfaction.
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY


    Any person who is requested to consent to participate as a subject in a research study involving a medical /dental experimental procedure, or who is requested to consent on behalf of another, has the right to:
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY

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

Schedule Your Appointment with the Holistic Dentist

Every service we offer is aimed at improving your overall health. We offer several procedures that eliminate the need for surgical incisions, reducing your discomfort, downtime, and the need for multiple visits. Call our office to schedule your consultation today.