Teeth Whitening

Name*

First NameLast Name

Date of Birth*

Address*

Street Address

Street Address Line 2

Postcode

Mobile phone*

Email*

example@example.com

Please select any conditions that apply to you:

Please list any allergies:

Please list any pills/medications:

If female, are you or do you think you may be pregant?

If you smoke, how many cigarettes do you smoke per day?

If you smoke, how many years have you smoked for?

How many units of alcohol do you drink per week?

How many times per day do you brush your teeth?

Do you brush your teeth with fluoride toothpaste?*

How often per week do you floss your teeth?

Name and address of your doctor:*

This is a consent form for whitening your teeth. Everything we have discussed
verbally is documented in this form for yours and our record.

• Whitening can only be performed in a healthy mouth. We would have
assessed your mouth to ensure it is healthy before commencing. However
if you have any pain or other concerns regarding the health of your mouth
please speak to us regarding this.
• We are using hydrogen peroxide to whiten your teeth at levels legally
allowed in the European Union. You will be using whitening trays made
specifically for your mouth for this procedure. If you lose or damage
these trays there will be an additional cost to replace them.
• It is your responsibility to follow the ‘wear’ instructions that we have
provided you.
• There are no guarantees as to the degree of whitening of your teeth and the
amount of whitening varies with the individual.
• Your teeth will take approximately take 4 weeks to whiten, however you
may wish to whiten your teeth for longer if your desired results are not
achieved within this time period.
• We will supply you with 4 weeks worth of bleach and bleaching trays. If
your desired results are not achieved you will have to purchase additional
bleach, at an additional cost from the practice.
• It is your responsibility to inform us if you are pregnant, breast-feeding or
have any known allergies/sensitivity to any bleaching products.
• Any crowns, bridges or filling materials in your teeth will not bleach and
may require replacement following the bleaching procedure, the charge
of which is not included in the cost of the whitening treatment.
• You are likely to suffer from mild sensitivity especially in the first few
days. We advise youtouse anti-sensitive toothpaste during the treatment
e.g.Sensodyne or Colgate sensitive pro relief. Occasional days off and
loading your tray with anti-sensitive toothpaste rather than bleach may
help. It is unlikely that you will suffer from severe sensitivity. Though
rare, there are instances where the bleaching procedure may need to be
stopped due to sensitivity, if this is the case your money will not be
refunded.
• Ensure you wipe away excess from the gums or gum irritation may occur.
• We advise you to abstain from red wine, smoking, tea, coffee and curries
during the treatment as this will hinder progress of the whitening. The
consumption of the aforesaid will also determine how long the teeth will
remain your desired shade.

1. I have read and understand the above information and the information
given to me verbally by the dentist.
2. The risks and benefits have been explained to me and I understand them.
3. I understand there are no guarantees as to the degree of whitening of my
teeth.
4. I have had the opportunity to ask questions, and my questions have been
answered satisfactorily.
5. I do not suffer from any of the medical conditions described or from
any other condition, which may result in me being unsuitable for
whitening treatment.
6. I consent to the treatment proposed and confirm my understanding and
acceptance of the associated risks outlined to me.
7. I agree to be responsible for payment of services rendered on my behalf.

Signature*