Whitening Teeth Consent Form

Teeth Whitening Consent Form

Thank you for Choosing EN Signature Brows and Beauty Studio for your services. We love to give our clients the best quality service. Please fill out the form below.
Overview & Expectations

I understand that the results can not be guaranteed a steeth whiten differently for each individual. If you have grayish teeth, teeth may become a lighter shade of gray but will not change to a white shade. I also understand that this procedure and home care treatment are not intended to whiten artificial teeth, caps, crowns, teeth with filings, veneers or porcelain, composite, other restorative materials or tetracycline stains. I understand that the longevity of my whitening results will varybased on the types of food and drink that I consume, brushing habits, and other daily maintenance. I understand that if any sensitivity occurs that it should only be temporary. I understand that I may see some blanching on my gums after using the product, which is a normal reaction to hydrogenperoxide; it will only be temporary and generally passes before leaving the studio. Use of the product is not recommended for children under 14 or for women that are pregnant or breast feeding. It is also not recommended for any one with periodontal disease or gingivitis as this can contribute to increased sensitivity.
Name*

First NameLast Name
Phone Number
Please enter a valid phone number.
Email*
example@example.com
Occupation
I UNDERSTAND THAT IF ANY OF THE 8 STATEMENTS BELOW APPLY TO ME OR IF I AM UNSURE IF THEY APPLY TO ME, THAT I SHOULD CONSULT MY DENTIST BEFORE CONTINUING WITH A TEETH WHITENING PROCEDURE:
Do you have a severe gag reflex?*

YesNo
Are you prone to gum sensitivity?*

YesNo
Do you have sensitivity to sunlight or other forms of direct light?*

YesNo
Are you taking any medications that increase your sensitivity to sunlight or to other forms of direct light?*

YesNo
Do you wear braces or have loose crowns, broken or fractured teeth, unfinished dental workor grayishteeth as a result on tetracycline?*

YesNo
Have you had any oral surgery or extractions within the last 60 days?*

YesNo
Do you have existing tooth decay, untreated gingivitis or periodontal disease?*

YesNo
Are you allergic to any of the following ingredients? IF SO, DO NOT USE THIS PRODUCT:*

Silicone Mouth Tray (latex free). (If allergic to Silicone avoid treatment)Carbamide Peroxide, Menthol, Mint Flavoring, Propylene Glycol, Kosher Glycerin,Triethanolamine. (If allergic to any ingredients avoid treatment)Cotton, Soybean oil, and Vitamin E. (Our Vitamin E is soy based, if you are allergic to soy or any other ingredients avoid use of swab.Yes, I'm allergic to one or more of the above ingredients and cannot use this product.None, I'm not allergic to any of the above ingredients.
I give Elizaveta Neginskaya permission to take, publish and reproduce photographs of me, my face, and/or my eye area, both before and/or after the procedure for advertising and other purposes.*

YesNo
Instructions after using the Product:

I will be required to refrain from consuming any substances that could discolor my teeth for the first 48 hours after treatment.These substances include: coffee, teas, and colas, ALL tobacco products, mustard or ketchup, red wine, soy sauce, berries, berry pie, and red sauces. I understand I should avoid eating or drinking any dark liquids or foods and/or smoking within 24 hours after the treatment(s).
I am 18 years old or older.

Yes, I am 18 years old or olderNo, I am not 18 years old. I have a parental and/or guardians consent with a signature below.
No I am not 18 years old. I have a parental and/or guardians consent with a signature. By signing this you understand all possible risks of this service.

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Print Parental/Guardians name:
first and last name
I understand that liability is limited to the amount paid for my teeth whitening procedure and since everyone is different, whitening results will vary by individual. I also understand it is recommended that I consult with my dentist if I experience any problems after any teeth whitening procedure. I have read and understand all information above..*

Clear
REFUND POLICY: Individual services, promotional services, sale services, series services, gift certificates purchased for yourself or for another individual are absolutely non-refundable.This applies to all of the procedures offered at the salon. There are NO REFUNDS on any procedures or services we have already initiated or already completed. NO EXCEPTIONS.*

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Today's Date*

MonthDayYear
Date
Please provide an email for follow up care.*
example@example.com
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Teeth Whitening Consent Form