6600 Mercy Ct., Ste. 220 Fair Oaks, CA 95628
Receipt of the California Dental Materials Fact Sheet
I have received a copy of The Dental Board of California's Dental Materials Fact Sheet. (Revised 05/04)
Yes, I acknowledge receiving the Dental Materials Fact Sheet
My dentist has explained the reasons for recommending a specific type of dental restoration material.
Yes, the explanation was provided
I have discussed the pros and cons of amalgam restoration with my dentist.
Yes, amalgam restoration was discussed
If I have had unusually sensitive reactions to other materials in the past, I have discussed this sensitivity with my dentist prior to restoration work.
Yes, I have discussed any sensitivity issues
I have had a chance to ask any questions I may have, and have received satisfactory answers to those questions.
Yes, all my questions were answered satisfactorily
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Date