They have explained to me that:
Although one or more of my subjective or objective signs or symptoms may resemble the signs or symptoms of mercury toxicity, I understand that this does not mean that I am suffering from the effects of mercury toxicity either directly or indirectly.
There is no scientific evidence that the removal of any amalgam filling will cure or improve any signs, symptoms, problems or conditions that I may have. I also understand there are no scientific tests which can show that removal of my filling will cure or improve any symptoms I have.
Any sign, symptom, problem, or condition that I have outside my mouth may involve a general health or medical question. Dr. Azouz is limiting advice to my mouth, and recommends that I consult a physician for any general health or medical concerns or questions I have. Further, he has not told me or represented to me that replacing my amalgam filling or non-precious metals would have any effect on me at all.
For any material chosen to replace dental amalgam, the advantages and disadvantages of the material chosen have been explained to me, including issues such as possible sensitivity, wear or breakage, galvanism(differing metals), and those regarding longevity.
As might occur with the placement of amalgam, gold, or any material, I understand there are situations beyond Dr. Azouz's control that may necessitate root canal treatment or removal of a tooth despite precautions taken and proper procedures utilized. Consequences of removal of fillings also include, but are not limited to: nerve damage, sensitive teeth, sensitive or receding gums, broken teeth, the necessity for crowns, or the loss of the tooth.
My questions concerning the treatment plan recommended by Dr. Azouz and his team, and I agreed to by me, have been fully answered. I have read this statement and understand if fully. I understand the above and wish to undergo the treatment plan outlined by Dr. Azouz and intend to follow all recommendations to the best of my ability. I am requesting treatment including replacement of my amalgam fillings for the reason(s) checked below: