COMPOSITE FILLING DISCLAIMER

    I understand, for my own benefit, this is an amalgam free office and my dentist prefers composite filling material for my tooth/teeth.

    The differences between the two materials (silver colored and tooth colored filling) and cost will be explained to me once I agree to have the composite (tooth colored) filling placed instead of the amalgam (silver colored) filling.

    Patient/Parent or Legal Guardian

    Name:

    Signature:

    Date:

    Please enter your email address so you can get a copy of this agreement: