Teeth Whitening Consent Form
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I give my service provider permission to take before and after pictures for social media/marketing. We will not tag you or disclose your information on the pictures/post/advertising unless approved.
I understand that the results of my treatment cannot be guaranteed.
I also understand that whitening treatment results may vary or regress due to a variety of circumstances. I understand that almost all natural teeth can benefit from whitening treatments and significant whitening can be achieved in most cases. I understand that whitening treatments are not intended to lighten artificial teeth, caps, crowns, veneers or porcelain, composite or other restorative materials and that people with darkly stained yellow or yellow-brown teeth frequently achieve better results than people with gray or bluish-gray teeth. I understand that teeth with multiple colorations, bands, splotches or spots due to tetracycline use or fluorosis do not whiten as well, may need multiple treatments or may not whiten at all. I understand that teeth with many fillings, cavities, chips or cracks may not lighten and are usually best treated with other non-bleaching alternatives. I understand that provisionals or temporaries made from acrylics may become discolored after exposure to treatment. I understand that treatment is not recommended for patients with known sensitivity to resins, peroxides or glycols.
I understand that some of the potential complications of this treatment include, but are not limited to:
Tooth Sensitivity/Pain- During the first 24 hours after treatment, many people can experience some tooth sensitivity or pain. This is normal and is usually mild, but it can be worse in susceptible individuals. Normally, tooth sensitivity or pain following a treatment subsides after a few days, but it may persist for longer periods of time in susceptible individuals. People with existing sensitivity, recession, exposed dentin, exposed root surfaces and occlusal wear facets (severely worn teeth), damaged or missing enamel, cracked teeth, abfractions (micro-cracks), open cavities, leaking fillings, or other dental conditions that cause sensitivity or allow penetration of the gel into the tooth may find that those conditions increase or prolong tooth sensitivity or pain after treatment. Gum/Lip/Cheek Inflammation- Whitening may cause inflammation of your gums, lips, or cheek margins. This is due to inadvertent exposure of a small area of those tissues to the whitening gel. The inflammation is usually temporary which will subside in a few days but may persist longer and may result in significant pain or discomfort, depending on the degree to which the soft tissues were exposed to the gel. Dry/Chapped Lips- The treatment involves three (20) minute sessions during which the mouth is kept open continuously for the entire treatment by a plastic retractor. This could result in dryness or chapping of the lips or cheek margins, which can be treated by application of lip balm, petroleum jelly or Vitamin E cream. Cavities or Leaking Fillings- Most dental whitening is indicated for the outside of the teeth, except for patients who have already undergone a root canal procedure.If any open cavities or fillings that are leaking and allowing gel to penetrate the tooth are present, significant pain and damage to the tooth could result. I understand that if my teeth have these conditions, I should have my cavities filled or my fillings re-done before undergoing the treatment.
I understand that after treatment...
I will be required to refrain from consuming any substances that could discolor my teeth for the first 24 hours after treatment. These substances include: coffee, tea, colas, ALL tobacco products, mustard or ketchup, red wine, soy sauce, berry pie, red sauces and lipstick. I understand that there are other substances that could discolor my teeth which I should avoid during the first 48 hours after treatment. If I have any questions regarding any such substance, I understand that I can discuss it’s stain potential with my service provider. In signing this informed consent I am stating I have read this informed consent (or it has been read to me) and I fully understand it and the possible risks, complication and benefits that can result from the treatment and that I agree to undergo the treatment as described by my service provider/Charleston Lash & Beauty Bar.
By signing this document in the space provided I indicate that I have read and understand the entire document and that I give my permission for whitening treatment to be performed on me by service provider/Charleston Lash & Beauty Bar.
I understand that I must provide at least 48 hours notice for canceling or rescheduling appointments. Appointment reservation requires a credit card on file for services over $25, and cancellations with less than 48 hours notice will result in 50% charge of the service fee. No shows or cancellations within 24 hours will result in 100% charge of the service fee.
Yes, I understand.
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