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Teeth Whitening Eligibility
This form must be completed before your appointment.
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1
Name
*
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First Name
Last Name
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2
Phone Number
*
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3
Date Of Birth
*
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Date
Year
Month
Day
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4
Teeth whitening cannot be performed on anyone who hasn’t seen a dentist/hygienist in the past year. I understand this and I would still like to proceed with my appointment.
*
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Yes
No
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5
Any veneers, crowns, or fillings will NOT whiten from this treatment which could result in uneven whitening. If you have any of these in the front of your teeth I would suggest calling to discuss further. I understand this and I would still like to proceed with my appointment.
*
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Yes
No
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6
Teeth whitening cannot be performed during pregnancy. I understand this and I would still like to proceed with my appointment.
*
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Yes
No
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7
Teeth whitening cannot be performed on anyone who has untreated cavities, tooth decay, or gum disease. I understand this and I would still like to proceed with my appointment.
*
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Yes
No
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8
I understand that if I am under 18 years of age, a legal parent/guardian must sign the consent form AND be present for the entire appointment
Yes
No
Not Applicable
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Teeth Whitening Eligibility
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