Teeth Whitening Consent Form

Name

First Name Last Name

Email

example@example.com

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Date of Birth

Date

Dear Client,

You have a right to be informed about your condition and its treatment, so that you may decide whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give, or withhold your consent for treatment.

I understand that I will undergo Teeth Whitening treatment(s) using gel solution and a LED (Light Emitting Diode) device.
I understand that multiple treatments may be necessary to achieve desired results. Treatments may take from 15 minutes up to 30 min. Additional treatments may be necessary to achieve desired results. Results will vary per patient. I agree to adhere to all safety precautions and regulations during the treatment.
Possible Side Effects can include but are no limited to: Allergic reaction to the gel solution, tooth sensitivity and irritation of the soft tissues (particularly the gums). In rare cases the use of LED's can damage the pulp (soft tissue in the center of teeth).
I understand that I am no being treated by a dentist, my technician has no dental qualifications and that my teeth are not being examined for health, cavities, etc.
I am aware that I should be examined by a dentist at least 12 months prior to treatment. I will advise my technician if I had/have any cavities of other dental work in my mouth.
I understand that if I have veneers, porcelain or other dental materials in my mouth, that these materials can not get any whiter than their original color.
I understand that I may no be 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 technician.
If I am pregnant, I understand that I may receive the LED Teeth Whitening service, however I must first consult my doctor and deliver doctor's approval to your technician.
I have read and understand the procedure policies. I have been informed of the aftercare instructions. I understand that compliance with recomended pre and post procedure guidelines are crucial for healing, prevention of side effects and complications as listed above. The nature and purpose of the treatment has been explained to me. I have read and understand this agreement. I release Flawless Spa Retreat of Distinction and its staff from liability associated with the procedure. I certify that I am a competent adult at least 18 years of age. This concent form is freely and voluntarily executed and shal be binding upon my spouse, relatives and legal representatives.

Date:

Date

Sign:

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