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Holistic Dental Centre
44-56 Queens Drive, Lower Hutt, WELLINGTON, NZ
Tel: 04.569 9320 / Fax: 04 570 2376 --------------------------------------------

Consent For Amalgam Removal

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I _____________________ have requested that Dr Simon removes some or all of my amalgam fillings. I understand that it is the Health Department's and Dental Association's current viewpoint that there is no proven link between removal of amalgam fillings and health improvement.

Dr Simon has not promised me any improvement in my health from amalgam removal.

I understand that in larger fillings that composite is not strong enough and these teeth may require crowns or inlays. I understand that replacing my fillings may result in the death of the nerve of the tooth, requiring tooth removal or root filling.

Signed:_____________________

Date:___ / ___ / ___


Holistic Dental Centre