Teeth Whitening

Teeth Whitening

New Client Form
General Information:
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of your appointment:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Would you like to be added to our email list for specials and discounts?
How did you hear about Intricate Beauty Bar?
Dental History:
Have you whiten your teeth before?
If yes, please state when?
Do you have any crowns, bridges, veneers, or fillings?
If yes, please state where?
Do you have sensitive teeth?
When was your last dental visit?
Medical History:
Do you currently or have you had any of the following? Please check all that apply:
Are you pregnant?
Are you currently taking any medication? If yes, please explain:
Any known allergies ? If yes, please list:
Lifestyle:
Do you drink any of the following? Please check all that apply:
Do you smoke ?
By signing below, I agree to the following: I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information I agree that do not have any condition(s) that would make the requested treatment unsuitable will inform the technicion of any discomfort may experience to allow them to adjust accordingly. I agree to waive all liability toward my technician for any injury or damages incurred due to any misrepresentation of my health.
Name Printed
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Informed Consent for Teeth Whitening:
General:
Results Guarantee:
Potential Risks: Although whitening treatments are generally safe. I understand that there can be potential complications of this treatment include, but are not limited to:
Eligibility:
Name Printed
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: