Jay Jill Cosmetic Teeth Whitening Consultation Form

Name*

First NameLast Name

Cell Phone Number*

Area CodePhone Number

Home Phone Number*

Area CodePhone Number

Work Phone Number*

Area CodePhone Number

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Name*

First NameLast Name

Emergency Contact Phone Number*

Area CodePhone Number

If you checked any of the above question you may not be eligible for treatment. Please explain “Yes” answers here: *

MaleFemale

Are you age 18 or older?*

YesNo

How did you hear about Jay-Jill Cosmetics?*

Reason for teeth whitening? E.g., wedding, holiday*

Have you had any form of teeth whitening before?*

YesNo

If yes, please explain. If no type NA*

When was your last visit to a dentist / hygienist? Please provide details of any treatment performed: *

Please rate the sensitivity of your teeth to hot/cold:*

HighAverageLowNone

Do you have any cardiac or vascular disease thrombophlebitis condition?*

YesNo

Do you have any fillings in the FRONT?*

YesNo

Do you have any fillings in the BACK?*

YesNo

Do you have any crowns / veneers / bridges in the FRONT?*

YesNo

Do you have any crowns / veneers / bridges in the BACK?*

YesNo

Do your gums bleed when brushing or flossing?*

YesNo

Do you have any sores in your mouth?*

YesNo

Do you have any untreated dental issues or worn teeth?*

YesNo

Please explain “Yes” answer here. If no type NA *

Are your teeth discoloured due to trauma, medication or a genetic disorder?*

YesNo

Please explain “Yes” answer here. If no type NA *

Do you drink any of the following?*

Do you use tobacco products?*

YesNo

Are you, or suspect that you might be, pregnant or breastfeeding?*

YesNo

Are you allergic to latex?*

NoYes

Are you allergic to peroxide?*

NoYes

Are you allergic to carbamide?*

NoYes

Are you allergic to glycerine?*

NoYes

Are you allergic to anything not stated above?*

Do you have advanced UNTREATED diabetes?*

YesNo

Do you have a communicable disease?*

YesNo

Do you have high levels of Triglycerides (hereditary)?*

YesNo

Do you have any type of heart disease?*

YesNo

Do you have kidney disease?*

YesNo

Are you allergic to zinc or nickel?*

YesNo

Are you lactose or gluten sensitive?*

YesNo

Are you presently taking any medications?*

YesNo

If yes, list any medications you are presently taking? If no, type NA*

Are you allergic to any foods or medication?*

YesNo

List foods or medication you are allergic to?*

Do you have any other medical conditions not mentioned above?*

YesNo

Please explain “Yes” answer here. If no type NA *

Are you taking any vitamins/supplements?*

YesNo

Are you taking recreational drugs*

YesNo

Are you presently under a physician’s care?*

YesNo

Please explain “Yes” answer here. If no type NA*

Family or primary treating physician name and phone number: *

READ CAREFULLY – CONSENT TO TREATMENT

INFORMATION FOR CANDIDATES
The safety and effectiveness of teeth whitening in general is very high. Like all cosmetic procedures, there are limitations and considerations (which will be discussed below). Success is variable and cannot be guaranteed.

CONSIDERATIONS AND CONCERNS
Problems that can occur in teeth whitening are generally infrequent, and are usually minor in nature. Please read the following information. If you are concerned about these points please ask us before signing this consent form.

Tooth Sensitivity – Sensitivity is usually mild, but can be worse in susceptible individuals and should normally subside in 24 hours. People with existing sensitivity, cracked teeth, cavities, leaking fillings may find these conditions increase or prolong sensitivity .
Gum and Soft Tissue Irritation – Protective materials are placed in the mouth to prevent this occurring. Occasionally the whitening gel may come in contact with soft tissues in which case they cause some temporary irritation and/or white spots which should resolve within 5 days.
Fillings and Other Dental Restorations – Tooth colored fillings (composites), composite veneers/bondings, porcelain crowns, and/or porcelain veneers will not whiten evenly with your natural teeth or perhaps even at all. We may, however, be able to remove certain stains (e.g., tobacco) from the surface of these restorations.

Disclosure This treatment is a process and subsequent visits may be necessary in order to achieve the desired results. Subsequent visits are subject to additional charges per visit which depend on the amount of work needed. Actual results vary from person to person and The Jay-Jill Cosmetics Glamtique does not guarantee any specific result.

After Care After care instructions must be followed explicitly, whether given in writing or orally. Failure to follow after care instructions may compromise the final results of the treatment.
Before, During and After Pictures Before, during and after pictures or videos may be taken to document the treatment. These pictures or videos become sole property of JSW Models & Productions LLC, DBA The Jay-Jill Cosmetics Glamtique and may only be used for its legitimate business purposes.

Release I recognize that there are certain inherent risks associated with the above-described treatment and I assume full responsibility for personal injury to myself. In exchange for such treatment, I hereby fully release and forever discharge JSW Models & Productions LLC, DBA The Jay-Jill Cosmetics Glamtique, Jay-Jill Cosmetics (including its officers, members, owners, employees and agents) from any and all damages, costs, expenses, liabilities, causes of action, claims and demands, of whatever character, in law or in equity, whether known or unknown, direct or indirect, asserted or un asserted, and whether or not on account of myself, JSW Models & Productions LLC, DBA The Jay-Jill Cosmetics Glamtique or other third parties, or in any way arising out of the above described treatment I have requested to be performed. It is the intention of the parties that this agreement binds all parties whose claims may arise out of or relate to the treatment or services provided by JSW Models & Productions LLC, DBA The Jay-Jill Cosmetics Glamtique including any spouse or heirs of the client/patient and any children, whether born or unborn. Any legal or equitable claim that may arise from participation in the treatment shall be resolved under Florida law.
I agree to indemnify, hold harmless and defend JSW Models & Productions LLC, DBA The Jay-Jill Cosmetics Glamtique (including its officers, members, owners, employees and agents) against all third-party claims, causes of action, damages, judgments, costs or expenses, including attorneys’ fees and other litigation costs, which may in any way arise from the above described treatment I have requested.
Arbitration It is understood that any dispute arising as to malpractice of the treatment shall be decided by a neutral arbitrator. Any arbitration proceeding will be governed by Florida arbitration statute, the fees for the arbitrator will be split pro-rata among the parties and each party will be responsible for their own attorneys’ fees and costs. Any action to collect fees from the client/patient for the treatments performed may be brought in any court located in Florida and the prevailing party in such collection action shall be entitled to recover its reasonable attorneys’ fees and costs. Filing of any action in any court to collect any fee from the client/patient shall not waive the right to compel arbitration of any malpractice claim.
By signing this agreement I confirm that I am over the age of 18, I certify that I have read the above paragraphs, fully understand this consent and procedure form and herby consent to the indicated procedure(s). This means that I accept full responsibility for these and/or any other complications which may arise or result during or following the procedure which is to be performed at my request according to this agreement and I hereby agree to arbitration of any malpractice claim. I further understand that by signing this agreement, I surrender certain legal rights.

Financial Policy:
Thank you for selecting The Jay-Jill Cosmetics Glamtique for your cosmetic needs. We are honored to be of service to you.
Fees: All costs are payable in-full prior to initial treatment and are non-refundable.
Form of Payment:
We accept Credit Card, Debit Card and Cash. Checks are not accepted. All forms of payment are immediately run through an electronic processing system and immediately deposited into the electronic transfer system.
Collection: In the event this account is referred to an agency for collections or if an electronic check is returned, you agree to be responsible for all returned fees and any collection costs, including collection agency and/or attorney fees.

Date

Signature*

Cosmetic Teeth Whitening Consultation Form

Client Background

Dental History

Medical History