SunnaSmile Consent Form

SunnaSmile Consent Form
Name

First NameLast Name
Birth Date (must be 18yrs or older)*

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
S2S4S6S8S10S12S14S16S18S20S22S24S26S28S30S32S34S36S38S40
S2S4S6S8S10S12S14S16S18S20S22S24S26S28S30S32S34S36S38S40
EXPECTATIONS

You may feel a slight tingling or minor blanching of the gums, this is a normal and will usually dissapear in less than 4 hours. Your teeth will never be whiter than your gentic traits. White spots may appear if you have had braces, or have porous enamel, caps, crowns or veneers. Please be advised, your teeth can only be whitened to a certain shade and cannot be whitened to a certain shade and cannot go whiter than your genetic traits allow.
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
If you have answered yes to any of the above questions or if you have not had a dental cleaning in the last 6 months please consult your dentist prior to use.
AFTERCARE AND FOLLOW UP

For the first hour after use drink only water. Avoid any staining food or drinks for the first 24 hours. Please review the caution statement on the in-office and home kit prior to use.
RELEASE
I blanks , in consideration of the services provided, hereby release SunnaSmile and its employees, distributors and or dealers from all manner of actions, causes of action, which may arise from the use of any product, service or services provided. I have been advised to consult a dentist before initial treatment. I have read the above and certify that I have healthy teeth and gums.
Client Signature

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