TEETH WHITENING FORM
Name
First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
How did you hear about us?
Instagram
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Friend
Other
Previous Client
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List of Medications
Do you have any medical drugs allergies?
Yes
No
If yes what allergies?
Are you allergic to Vitamin E?
Yes
No
Are you allergic to Hydrogen Peroxide?
Yes
No
Woman, are you pregnant or nursing?
Yes
No
Have you ever used whitening products before?
Yes or No? if yes what kind?
Do you smoke cigarettes?
Yes
No
Todays Date
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Month
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Day
Year
Date
The amount of whitening cannot be predicted or guaranteed. Teeth will not whiten past your genetic whiteness (what you were born with). Yellow or Brown teeth white surface stains whiten easier than gray or bluish teeth. Striped or spotted teeth are difficult to whiten. Fillings, Crowns, or Veneers will whiten back to the original colour that they were first placed.
Initial
Our teeth whitening system uses 16% high intensity bleaching gels and a high density cold blue light, which activates the gel's components. This procedure may or may not require additional whitening in order to achieve your desired lightened shade.
Initial
Our whitening gel has adjusted PH (acidity) and conditioner to reduce teeth and gum sensitivity. All teeth react different In the unlikelyhood sensitivity occurs, it may be present for 1-2 days. Scientific articles have shown that the materials used in teeth whitening are safe and effective. It does not change the structure of teeth. It helps to achieve a white and brighten look.
Initial
Our whitening gels has conditioners and moisturizers in it to sooth the gums. if the gel comes in contact with them, tingling and blanching (white bumps) can occur on gums. these are not harmful in any way and will disappear in 1-2 days. All peoples gums react differently to the whitening gel.
Initial
If you have fillings that are breaking down, decay in teeth, erosion of the teeth, or exposed root surfaces due to periodontal disease, the gel will come in direct contact with these areas and may cause sensitivity during and after treatment. This sensitivity will go away in 1-2 days.
Initial
The amount of whitening varies with each individual. There are no guarantees to the degree of whitening
Initial
We guarantee change but cannot guarantee how much.
Initial
Additional whitening sessions maybe required to obtain the ultimate desired result.
Initial
I allow Yem at Beauty by Yem to take a before / after picture of my service - these photos may be used on our website, our Instagram or Facebook page etc.
Initial
Client Consent: I have read and initialed this consent form and understand the risks and benefits explained on it. I have had the opportunity to ask questions regarding this procedure. I consent to treatment and assume all responsibility for the risks described above.
Name
First Name
Last Name
Todays Date
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Month
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Day
Year
Date
Signature Technician
Date
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Month
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