TEETH WHITENING CLIENT FORM & WAIVER

Strict 24 Hour Change Cancel Fee

I agree to change/cancel my appointment within 24 hours to avoid the fee.

By filling out my credit card info I agree to a 24 Hour Change Cancel Fee of $25 - This will automatically be charged should I not show up for this or any other future appointments or do not change/cancel appointments with 24 hours notice.*

USDCancellation Fee

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Location*

South BayOther
Treatment #1 Date*

MonthDayYear
Date
Email*
example@example.com
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
By texting Sunless Beauty at 424-206-3401, you agree to receive text messages, conversational, marketing and appointment notifications messages from Sunless Beauty. Reply STOP to opt-out; Reply HELP for support; Message & data rates may apply; Messaging frequency may vary. Visit to see our privacy policy https://i18fq58bwcft3oog-72186134817.shopifypreview.com/policies/privacy-policyand for our Terms of Service.
Age*
You cannot get the treatment if you under age 12 and cannot sign the waiver if you are under the age of 18.
Starting Shade (For Office Use)
Ending Shade (For Office Use)
Over the age of 18. Cannot get the treatment if under 12 years of age.*

YesNo
You may feel a slight tingling or minor blanching of the gums, this is normal and will usually disappear in less than 4 hours. Your teeth will never be whiter than your genetic traits. White spots may appear if you have braces, or have porous enamel, this will usually disappear in 5 Minutes - 8 hours. The whitening gel is PH neutral and will not damage your enamel, caps, crowns or veneers. **Please be advised, your teeth/veneers can only be whitened to a certain shade original color of veneers.**
Exclusions for Treatment:

Please answer the following to the best of your knowledge or ability. If you answer yes to any of the following you are currently not a candidate to receive the treatment.
Have allergies or reactions to any ingredients in teeth whitening gel. List of ingredients can be provided upon request.*

YesNo
Have existing tooth decay, periodontal disease, or gingivitis*

YesNo
Has recently taken (Within 14 days) any photosensitive or on photosensitive medications. This includes antibiotics, chemotherapy, etc...*

YesNo
Pregnant or Breastfeeding*

YesNo
Have had oral surgery or extractions within the last 30 days*

YesNo
No - Wearing oral piercings (remove prior to use)

If you answered yes to any of the above questions or if you have not had a dental cleaning in the last 6-12 months please consult your dentist prior to use.

For the first hour after use, drink only water. For 24 hours avoid any staining food or drinks. Please review the caution statement on the in-office and home kit prior to use.
Release: In consideration of the services provided, hereby release Sunless Beauty or it's owners, affiliates, patterns, employees, distributors and or dealers from all manner of actions, causes of action, which may arise from the use of any product, service or services provided. I have been advised to consult a dentist before initial treatment. This agreement is governed by the laws of Los Angeles, California. I have read the above and certify that I have healthy teeth and gums.

Returns and cancellation policy for products & services purchased: No Refunds. Per any Covid related cancellations on either party only an online or store credit will be issued. Opened or used products are not refundable. Unopened products can be returned for store credit only plus a 20% restocking fee. No credits or returns after 14 days of purchase. I understand the cancellation and return policy for this order.
I have read and agree that I understand the contradiction, liability, 24 hour cancelation & refund policy stated above. Client Signature. If a minor parent or guardian signature.*

Clear
Date*

MonthDayYear
Date
Sunless Beauty

Additional Treatment Visits
For my additional treatments I consent to the previous waiver singed and agree that nothing has changed from previous information and contradictions.
Signature

Clear
Treatment #2

MonthDayYear
Date
Starting Shade (For Office Use)
Ending Shade (For Office Use)
Treatment #3

MonthDayYear
Date
Starting Shade (For Office Use)
Ending Shade
Should be Empty:

Strict 24 Hour Change Cancel Fee

Exclusions for Treatment:

Sunless Beauty