TO OUR CUSTOMERS: You have a right to be informed about your condition and it’s treatment, so that you may decide whether or not you’re willing to undergo the procedure with us after knowing the risk and hazards involved. This disclosure is meant to inform you about the treatment that you are about to undergo with us and for explanation of any risk factors associated with this treatment. understand that I will undergo Teeth Whitening treatment(s) using a gel solution and a LED (Light Emitting Diode) device. 2. I understand that multiple treatments may be necessary to achieve my desired results. Treatments can take anywhere from 30 minutes up to 90 mins. Additional treatments may be necessary to maintain desired results. No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. Results of the procedure will vary per patient. I agree to adhere to all safety precautions and regulations during the treatment. 3.Possible side effects can include but arenot limited to: Allergic reaction to the gel solution, tooth sensitivity and irritation of the soft tissues (particularly the gums In extremely rare cases. I understand that repeated/over excessive teeth whitening may damage my teeth. 4. I understand that I am not being treated by a Dentist, but in fact I’m being treated by licensed and certified dental professionals. 5. I am aware that I should be examined by a Dentist prior to treatment. I will advise my certified dental professional if I had/have any cavities or other dental work in my mouth. 6. I understand that if I have veneers, porcelain, or other dental materials in my mouth, that these materials cannot get any whiter unless I’ve had them for at least 6 or more years with accumulated surface stains over the years. 7. I understand I am not a good candidate for this procedure if I have significant periodontal disease, fillings that may be breaking down, unfilled cavities, or chipped or worn teeth. I understand if I have any of these conditions I will advise my certified dental professional. 8. If I am pregnant I understand that I may receive the LED teeth whitening service, however; I must first consult with my dentist once my first trimester is complete. 9. If I am provided with an at home whitening treatment kit, I will follow the instructions provided by my technician. I will not use the product more than instructed. 10. I have read and understood the Pre and Post-Treatment instructions. I agree to follow these instructions carefully. I understand that compliance with recommended pre and post procedure guidelines are crucial for healing, prevention of effects and complications as listed above.
The nature and purpose of the treatment have been explained to me. I have read and I understand this agreement. All of my questions have been answered to my satisfaction and I consent to the terms of the agreement.