Tooth Whitening Consent Form
Dr Elena Harley street 86
Patient Information
Name
*
First Name
Last Name
Age
*
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health and Dental Information
Do you have any known tooth decay or broken teeth?
Please Select
Yes
No
I consent and give permission for before after photo taken and use of it for any needed reason
your condition
suffer sensetive teeth
do you ve sore/coldsore
breast feeding/pregnant
Braces or had one removed recently
had been told by dentist not to do teeth whitening
Gum disease,receding gums,teeth decay
Do you have any allergies to hydrogen peroxide ?
If yes, then please specify it on the field above.
Are you currently taking any medications?
If yes, then please specify it on the field above.
Do you have any medical conditions that we should be aware of? (Communicable disease, cardiovascular problems, diabetes, etc.)
If yes, then please specify it on the field above.
Waiver and Consent
*
I authorize (Dr Elena) and other professionals who deliver the treatment which was appointed by Dr Elena to perform this procedure to me. The doctor or professionals explained the nature of the treatment and how it will help me.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.I release (Dr Elena) for any responsibility in case of an accident, illness, or injury.I acknowledge that all information I provided int his form is true and accurate.
Date Signed
-
Month
-
Day
Year
Date
Signature
*
I consent for before after photo and use of it for any needed reason
Submit
Should be Empty: