'I Am' Different than a Traditional Dentist

Patient Name *

First Name Middle Name Last Name

'I Am' Different than a Traditional Dentist

DISCLAIMER:

The California State Board of Dental Examiners and other sate Dental Board, The American Dental Association (ADA), The American Association of Endodontists (AAE), The American Association of Oral and Maxillofacial Surgeons (AAOMS), The American Academy of Periodontoloty (AAP) and The North American Dental Schools do not agree that past extraction sites, root canaled teeth or ADA approved restorative dental materials (Dental Mercury Amalgam fillings) can be harmful to patient's health. Dr. Azouz believes they may.

Dr. Azouz makes no claims that treating any of these conditions will improve a patient's overall health.

*

I acknowledge that I have been made aware of this disclaimer.

Signature *

Clear

Date *

Date

(Your digital signature (full name) is as legally binding as a physical signature.)