Wholeistic Choices
Review the options, answer the fluoride and suction questions, then sign and date the form.
Patient name
*
First Name
Last Name
Patient date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
I am interested in the following options. (Please check the appropriate box for each statement.)
I request the use of materials that do not contain fluoride. I understand this is a personal decision based on my research of the potential damage caused by fluoride use.
*
Yes
No
Please utilize a rubber dam to isolate the teeth being treated from the rest of my mouth. Additional low-volume suction will be used under the dam to attempt to minimize mercury vapors. Please use additional suction and room air filtration during my procedure to remove metal and mercury from my mouth and the ambient air in the room.
*
Yes
No
Signature (patient, or parent/guardian for a child)
*
Relationship to patient
*
Self
Parent
Guardian
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: