Teeth whitening is designed to lighten the color of your teeth. Results CANNOT BE GUARANTEED, as teeth whiten differently for each individual depending on his or her genetic traits and types of stains. Also be aware that all forms of health treatments, including teeth whitening, have some risks and limitations. I acknowledge that I am purchasing a self-administered teeth whitening kit that is designed to whiten the color of my teeth. As part of my purchase I am asking for assistance with the use of my kit, and I understand that I will be allowed to use a specifically designed LED light to accelerate the whitening process.

CANDIDATES: Use of this product is not recommended for children under 16 or for women that are pregnant or breastfeeding. It is also not recommended for anyone with periodontal disease or gingivitis as this can contribute to increased sensitivity. If you have grayish teeth, they may become a lighter shade of gray but will not change to a white shade. This procedure is NOT INTENDED to whiten artificial teeth, caps, crowns, teeth with fillings, veneers or porcelain, composite, other restorative materials or tetracycline stains. I UNDERSTAND THAT IF ANY OF THESE STATEMENTS BELOW APPLY TO ME OR IF I AM UNSURE IF THEY APPLY TO ME, THAT I SHOULD CONSULT MY DENTIST BEFORE CONTINUING WITH A TEETH WHITENING PROCEDURE: • Do you have a severe gag reflex? • Are you prone to gum sensitivity? • Do you have sensitivity to sunlight or other forms of direct light? • Are you taking any medications that increase your sensitivity to sunlight or to other forms of direct light? • Do you wear braces or have loose crowns, broken or fractured teeth, unfinished dental work or grayish teeth as a result of tetracycline? • Have you had any oral surgery or extractions within the last 60 days? • Do you have existing tooth decay, untreated gingivitis or periodontal disease? • Are you allergic to any of the following ingredients? IF SO, AVOID TREATMENT Carbamide or Hydrogen Peroxide, Sodium Hydroxide, Carbomer, Carboxymethyl, Potassium Nitrate, Menthol, Mint Flavoring, Propylene Glycol, Glycerol, Poly Vinylpyrrolidone, Triethanolamine, Cotton, Soybean oil, or Vitamin E. (Our Vitamin E is soy based, and includes sunflower oil, sweet almond oil, and aloe vera- if you are allergic to soy or any other ingredients listed avoid use of swab)

POTENTIAL PROBLEMS: Possible side effects can include but are not limited to: allergic reaction to ingredients in products, tooth sensitivity, and irritation/inflammation of the soft tissues (particularly the gums). I understand that if any sensitivity/irritation occurs that it should only be temporary and rinsing with warm salt water may relieve it. Also, you may see a white film or blanching of the gums which is a normal reaction to the ingredient peroxide.

AFTERCARE: I understand I should avoid eating or drinking any staining substances such as tomato sauce, tea, coffee, red wine, dark liquids/foods, and tobacco substances for 48 hours after the whitening treatment. The pigments found in food and drinks will re-stain your teeth, along with smoking. Some individuals may require an additional session. I understand it is highly recommended that I, in conjunction with using teeth whitening maintenance products, maintain regular visits to my oral Hygienist for optimum results. One to three sessions are recommended for optimal results. I understand that I am not being treated by a dentist, staff has no dental qualifications, and that my teeth are not being examined for health, cavities, or cleaned.

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I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, staff, and other clients and their families. I voluntarily seek services provided by Vibes & Visuals. I acknowledge that I must comply with all set procedures to reduce the spread of infection while attending my appointment. I attest that: * I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell. * I have not traveled internationally within the last 14 days. * I have not traveled to a highly impacted area within the UK in the last 14 days. * I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19. * I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities. * I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.

By SUBMITTING AND SIGNING THIS FORM, I acknowledge, consent and agree to the following: I give my permission to receive the above selected services. I understand that staff does not diagnose illnesses or injuries, or prescribe medications. I understand risks are associated with every service. I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience an allergic reaction. I acknowledge that my service is strictly elective and no medical claims or results are guaranteed. I understand that there may be additional risks based on my physical condition and health history. I give permission for the use of my pictures and videos. I understand that it is my responsibility to inform staff of any discomfort I may feel during the session so he/she may adjust accordingly. I have been given a chance to ask questions about the session and my questions have been answered. I consent that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments. I, therefore, release Vibes & Visuals and its staff from all and any liability associated with any injuries and or current and future conditions resulting from procedures or products. This liability waiver and release extends to the studio together with all owners, partners, and employees. Any guest under 18 must have a parent or legal guardian also sign below.