I, {patientName} request that my dentist, Dr. Beata Carlson, remove dental silver mercury amalgam fillings or other metals from my teeth and to replace them with dental materials presently considered bio-compatible based on existing scientific options.

These materials include composite resins (plastics), ceramic and porcelain.

Although 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 mainstream scientific evidence that removing amalgam fillings from my teeth will cause the cure of amelioration of any health problems or conditions. Furthermore, my dentist has made no representation that replacing my amalgam fillings or metals will affect or cure any specific symptoms or medical problems I may have. There have been reported cases of removal of old silver mercury fillings leading to worsening of medical conditions. To help avoid this, one should consult an experienced alternative medicine practitioner who is familiar with handling mercury toxicity. We can refer you to such a doctor. 

If a composite resin is the material chosen to replace dental amalgam and other non-precious materials 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 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 these are situations beyond the control of my dentist in removing old dental materials and placing of newer materials that may cause adverse reactions, may necessitate endodontic treatment, and/or removal of existing teeth despite precautions taken and proper procedures utilized.

My questions concerning the treatment plan recommended by Dr. Beata A. Carlson and Associates have been answered. I have read and understood this statement and am satisfied that I have been fully informed.