Teeth Whitening

Date*

Date

Name*

First NameLast Name

Date of Birth*

Date

Age*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Email*

example@example.com

Identifies as*

FemaleMaleNon-Binary

Contact In Case Of Emergency

Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Relationship*

How did you hear about us?*

Walked byFacebook/InstagramOnline SearchReferral

If referred, by whom?

May we take photographs for the purpose of documentation, potential advertising and promotional purposes?*

YesNo

I consent to “before and after” photographs for the purpose of documentation, potential advertising and promotional purposes.*

Initial

EXPECTATIONS:

People with healthy teeth and gums but who have stains or a yellowish tint seem to get the best result.
You will not experience any heat or discomfort. On some occasions, you may feel a little tingling or perhaps a slight sensitivity.
Teeth and/or gums may be sensitive for a short time after treatment.
You may see temporary bleaching to the gums but this is normal and will disappear, usually in less than a day.
Your teeth will never be whiter than your genetic traits. All teeth bleach differently.
Possible white spots or demineralization may appear on people who have had braces or who have porous enamel, but this will disappear within 24 hours.
The treatment will not whiten or damage veneers, crowns or false teeth.

EXCLUSIONS FOR TREATMENT: (Please answer the following)*

Have allergies or reactions to either carbamide, peroxide or glycerin.Have existing tooth decay, periodontal disease or gingivitis.Are photosensitive to light or on any photosensitive drugs.Are pregnant, suspected of being, or are breastfeeding.Under the age of 18.Have had oral surgery or extractions within the last 28 days.Are wearing a piercing or metal object in the oral cavity. (Please remove, as they may turn black)None

Have you gotten your teeth whitened before?*

YesNo

When was the last time?*

When was your last dental cleaning?*

Do you use a manual or electric toothbrush?*

ManualElectric

Do you use a soft or hard bristle toothbrush?*

SoftHardNot sure

Do have sensitivity when eating or drinking hot/cold food or drinks?*

YesNo

Check all of the following that apply :*

Acknowledgment and Waiver*

I understand that Emerald Reign Artistry, LLC and its staff reserves the right to refuse to perform treatments on anyone whom he/she deems to have a condition for which treatments are contraindicated.I allow and authorize Emerald Reign Artistry, LLC and its staff to perform this procedure to me.I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment has been explained to me, along with the risks and hazards involved.I understand the technicans are not qualified to diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. I further understand that a consult before treatment should not be construed as a substitute for medical examination, diagnosis, or treatment.I understand the risk and complications if I do not follow the instructions given to me after the procedure which involves post-treatment and follow-ups.Because certain treatments should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly and have not withheld any information that may be relevant to my treatment. .I agree to keep the esthetician updated as to any changes in my medical profile during any session and understand that there shall be no liability on the estheticians part should I fail to do so.I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release Emerald Reign Artistry, LLC and its staff from any liability associated with any injuries and/or current and future conditions resulting from the skincare procedures or products and assume full responsibility thereof.I understand, have read and completed this questionnaire truthfully.

By signing below, I acknowledge that I have read and fully understand this agreement and all information detailed above and hereby agree to comply to them.*

Name*

First NameLast Name

Date*

Date

For a minimum of 24 hours after the process, please avoid consuming coffee, tea, dark coloured soda, red wine, curry, beetroot and other food or drink that would stain the teeth. A good rule of thumb is; if it would stain a white shirt it could stain your teeth. If your teeth are sensitive you can use desensitizing toothpaste for relief. Of course, we suggest that you brush and floss as directed by your dentist. There is no guarantee as to the longevity of the results therefore we recommend monthly maintence sessions or at home whitening kits.

"Products containing peroxides are not recommended for use by children under 12 years of age. Use for periods of longer than 14 days is to be only under the supervision of a dentist. If irritation (such as redness, swelling, soreness) of the gums or the mouth occurs, discontinue use and consult a dentist. Avoid swallowing the cosmetic or part thereof. Avoid direct contact of the active surface of the tooth whitening product with the gums and/or salivary flow. Avoid contact of the product with the eye."

By signing below, I acknowledge that I have read and fully understand this agreement and all information detailed above and hereby agree to comply to them.*

Name*

First NameLast Name

Date*

Date

Teeth Whitening

AFTERCARE AND FOLLOW-UP