Tooth Whitening Consent/and consultation Form

Tooth Whitening Consent/and consultation Form

Glo Up Smiles LLC
Patient Information
Name*

First NameLast name initial
Age
Date of Birth

MonthDayYear
Date
Email*
example@example.com
Phone Number*

Area CodePhone Number
Consultation form
When was your last dental visit?
Have you had your teeth whitened before?
Do you have any medical conditions or taking medication?*
If yes, then please specify it on the field above.
Do you have any allergies to latex, peroxide, Carbamide or glycerin?*
If yes, then please specify it on the field above.
Do you have any known untreated dental issues? Cavities, broken teeth or have recently undergone any dental procedures in the past 3 months?
If yes, then please specify it on the field above.
Do you have discolored teeth due to trauma, medication, or a genetic disorder?
If yes, then please specify it on the field above.
Do you have crowns, bridges, veneers on your front teeth?
Do you drink coffee, tea, red wine or energy drinks, soda pop or smoke tobacco?
If yes, then please specify it on the field above.
Do your gums bleed when brushing or flossing?
Are you pregnant (or suspect that you may be) or breastfeeding? *
INFORMED CONSENT FORM/ OFFICE TOOTH WHITENING TREATMENT INTRODUCTION
This information has been given to me so that I can make an informed decision about having my teeth   Initial*
whitened. I may take as much time as I wish to make my decision about signing this informed consent   Initial*
form. I have the right to ask questions about any procedure before agreeing to undergo the procedure.   Initial*
would like to have my teeth lightened via the "in-office" technique.   Initial*

DESCRIPTION OF THE PROCEDURE

In-Office Whitening is a procedure designed to lighten the color of my teeth using a hydrogen
peroxide gel. The In-Office Whitening treatment involves using the gel to produce maximum whitening

results in the shortest time possible.. Initial*

During the procedure the whitening gel will be applied to my teeth for two or three 20-minute sessions, with an optional fourth 20-minute session. During the entire treatment, a plastic retractor will be
placed in my mouth to help keep it open and the soft tissues of my mouth (i.e. my lips, gums, cheeks and tongue) will be covered to ensure they are not exposed to the gel.   Initial*

Lip balm may also be applied as needed and I will be provided protective eyewear for my eyes. After
the treatment is completed, the retractor and all gel and tissue coverings will be removed from my mouth.

Before and after the treatment, the shade of my upper-front teeth will be assessed and recorded.   Initial

Risks of treatment

I understand that In-Office whitening treatment results may vary or regress due to a variety of
circumstances. I understand that almost all natural teeth can be lightened from In-Office Whitening
treatment. I understand that In-Office Whitening treatments are not intended to lighten artificial teeth,
caps, crowns, veneers or porcelain, composite or other restorative materials and that people with stained
teeth.
I understand that teeth with multiple colorations, bands, splotches or spots due to tetracycline use or
fluorosis do not whiten as well, and 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 the results of my In-Office Whitening cannot be guaranteed.
I understand that although my dental technician has been trained in the proper use of the In-Office
Whitening system, the treatment is not without risk. I understand that some of the potential complications
of this treatment include, but are not limited to:
Tooth Sensitivity is normal and is usually mild, but it can be worse in susceptible individuals.
Usually, tooth sensitivity or pain following a whitening 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 large wear facets (severely worn teeth), damaged or missing
enamel, cracked teeth, 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 whitening treatment
After the whitening treatment, it is natural for teeth that underwent the whitening treatment to regress
somewhat in their shading after treatment. This is natural and should be very gradual but it can be
accelerated by exposing the teeth to various staining agents. Treatment usually involves wearing a take
home tray or repeating the whitening treatment.
I understand that the results of the whitening treatment is not intended to be permanent and secondary,
repeat or take-home treatments may be needed further to maintain the tooth shade I desire for my teeth. I
understand that after treatment, I will be required to refrain from consuming any substances that could
discolor my teeth for the first 48 hours after treatment. These substances include: coffee, teas, and colas,
ALL tobacco products, mustard or ketchup, red wine, soy sauce, berries, berry pie, and red sauces.
Since it is impossible to state every complication that may occur as a result of whitening treatments, the
list of complications in this form is incomplete. The basic procedures of whitening treatments and the
advantages and disadvantages; risks and known possible complications of alternative treatments have
been explained to me by my technician and my technician has answered all my questions to
my satisfaction.
In signing this informed consent I am stating I have had this informed consent (or it has been read to me)
and I fully understand it and the possible risks, complications and benefits that can result from the
whitening treatment and that I agree to undergo the treatment as described by my technician..
SIGNATURES
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 the In-Office whitening treatment to be performed on me..
Signature of the Patient*

Clear
Date Signed

MonthDayYear
Date
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