All Oregon Dentists Must Obtain Informed Consent from Patients before using Amalgam on them. Senate Bill 681 (2003 Act).

NOTICE TO PATIENTS:

1. 1.Mercury vapor is released from dental materials containing mercury.
   

2. 2.The human nervous system is very sensitive to all forms of mercury.
   

3. 3.Mercury vapors are more harmful than other forms of mercury, because more mercury in this form reaches the brain.
   

4. 4.Exposure to mercury can permanently damage the brain, kidneys and a developing fetus.
   

5. 5.The effects of mercury on brain function may include irritability, shyness, tremors, changes in vision or hearing and memory problems.
   

6. 6.Short-term exposure to high levels of mercury vapors may cause side effects, including lung damage, nausea, vomiting, diarrhea, increases in blood pressure or heart rate, skin rashes and eye irritation.
   

7. 7.Fetuses and very young children are more sensitive to mercury than are adults. Mercury in the mother's body passes into the fetus and can pass to a nursing infant through breast milk.
   

8. 8.The harmful effects of mercury that may be passed from the mother to the developing fetus include brain damage, mental retardation, in coordination, blindness, seizures and an inability to speak. Children poisoned by mercury may develop problems of their nervous and digestive systems and kidney damage.
   

Patient acknowledgement:

My signature attests that I have read & understood this description of the effects of mercury as set out in this informed consent form. I consent to the use of amalgam containing mercury. I have been provided with a signed copy of this form.

Patient's signature or guardian's signature:...............................................

If patient is incapacitated, name of patient:...............................................

Dentist's signature:....................................................................................

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