1. I hereby authorize Dr. Jeffrey Tatarin to treat my condition(s) as specified below. The procedure(s) necessary to treat the condition(s) have been explained to me and I understand the nature of the procedure(s) as follows:
Removal of existing dental amalgam restoration(s) which will be replaced by resin restoration(s) and/or crown(s).
2. I have been informed of my current dental diagnosis and of possible alternative methods of treatment (if any).
3. I further understand that this is an elective procedure, which other forms of treatment or no treatment at all are choices that I have, and I have discussed the known risks of these other forms of treatment with Dr. Tatarin.
4. Dr. Tatarin has explained to me that there are certain inherent and potential risks in ANY treatment plan or procedure. In this specific instance such risks include, but are not limited to, the following:
a. Nerve inflammation resulting in hot or cold sensitivity
b. Nerve impairment resulting in prolonged numbness or tingliness to the lip or tongue
c. The need for endodontic therapy (root canal treatment) or tooth extraction
d. Broken tooth or Cracked Tooth Syndrome
e. A shorter length of serviceability of the restoration with the need for more frequent replacement
f. In cases where the existing restorations are very large, the use of a full coverage crown or are suggested
6. It has been explained to me that, during the course of the procedure(s), unforeseen conditions may be revealed that necessitate an extension of the original procedure(s) or different procedure(s) than those set forth in paragraph 1 above. I, therefore, authorize and request that Dr. Tatarin perform such procedure(s) as are necessary and desirable in the exercise of professional judgment. The authority granted under this
paragraph 6 shall extend to the treatment of all conditions that require treatment and are not known at the time the original procedure(s) commenced.
7. I understand that removal of my dental amalgam(s) may not improve my general health and may not reduce any symptoms I may have relating to chronic mercury toxicity, allergy and/or sensitivity. In fact, removal of my dental amalgam(s) may make my health issues worsen.
8. I further understand that Dr. Tatarin will be removing my dental amalgam(s) according to the most current safe mercury amalgam removal technique. I also understand that the use of all these protective measures does not eliminate my exposure to mercury particulate matter and vapor during the removal process, but does reduce my exposure to the best possible level.
9. I have been informed that an out-of-pocket fee per visit will be charged for the personal protection I will receive when removing my dental amalgam(s) (see paragraph 8). The fee will be $245 per visit and will be due at the time services are rendered.
10. It has been explained to me that, if I elect to use activated charcoal before or after the removal of my amalgams, there can be potential adverse interactions with the following drugs:
– CellCept® (mycophenolate mofetil)
– Tylenol® (acetaminophen)
– Digoxin
– Theophylline
– Tricyclic antidepressants, including
– Amitriptyline
– Amoxapine
– Desipramine (Norpramin)
– Doxepin
– Imipramine (Tofranil)
– Nortriptyline (Pamelor)
– Protriptyline (Vivactil)
– Trimipramine (Surmontil)
– Naltrexone
– Hydrocodone, morphine, oxycodone
– Birth control
11. It has been explained to me, and I understand, that a perfect result is not guaranteed or warranted and cannot be guaranteed or warranted.
12. I have been given ample opportunity to ask questions and any questions I have asked have been answered in a satisfactory manner.
13. I certify that I read and write English and fully understand this consent.
PLEASE ASK DR. TATARIN IF YOU HAVE ANY QUESTIONS CONCERNING THIS CONSENT FORM BEFORE SIGNING IT.
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