Composite Disclaimer

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.

I understand that my Insurance may not cover this expense and any difference the charges will be my responsibility. I agree to pay these charges at the time services are rendered.No, I do not want composite fillings and will call my insurance company to find a dentist who performs amalgam fillings.