Teeth Whitening Client Intake Form
Teeth whitening is designed to lighten the color of your teeth. The service is done using a special blue LED light and a carbamide peroxide gel that when combined rapidly speeds up the whitening process. Significant change can be achieved in the majority of cases, but the results cannot be guaranteed. The gel is designed to be gentle and safe. However, like any treatment, it has its risks and limitations. It is recommended to consult your dentist if you experience any pain or sensitivities.
Appointment Date
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Month
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Day
Year
Date
Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
How did you hear about us?
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Family/Friend
Google
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If you were referred, please state their name:
Please check if any of these applies to you:
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Severe gag reflex
Prone to gum sensitivity
Any sensitivity to sunlight or other forms of direct light
Currently taking any medications that increase your sensitivity to sunlight or to other forms of direct light
Have braces or have loose crowns, broken teeth, or other unfinished dental work?
You had any oral surgery or extractions within the last 90 days
You have existing tooth decay, untreated gingivitis or periodontal disease
To your knowledge, are you allergic to any of the following: Hydrogen Peroxide, Glycerin, Carbomer Sorbitol, Sodium Hydroxide, EDTA, Potassium Nitrate, or Silicone?
I don't have any of these concerns
Other
Cosmetic Teeth Whitening Agreement (please check to agree):
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My cosmetic teeth whitening treatment cannot be guaranteed, as teeth whiten differently for each individual depending on his or her genetic traits and types of stains. I also understand that my teeth whitening treatment is not intended to whiten artificial teeth, caps, crowns, veneers or porcelain, composite or other restorative materials.
The longevity of my whitening results will vary based on the types of food and drink that I consume, brushing habits, and maintenance. Secondary, follow up treatments maybe needed to maintain the tooth shade I desire. 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, colas, ALL tobacco products, mustard or ketchup, red wine, soy sauce, berries, berry pie, and red sauces.
Although uncommon, some clients can experience some tooth sensitivity during the first 24 hours after the whitening treatment. People with existing sensitivity, recently cracked teeth, micro-cracks, open cavities, leaking fillings, exposed roots, or other dental conditions that cause sensitivity may find that those conditions increase or prolong tooth sensitivity after the treatment. Please avoid any sort of cold or extremely hot foods (spicy included) within the first 24 hours of the Teeth Whitening Service.
I understand that whitening may cause inflammation of gums, lips and/or cheek margins. I may see white spots or film on my gums after the procedure which is a normal and temporary reaction to hydrogen peroxide. If any irritation does occur, it is generally short of duration and mild. Rinsing with warm salt water can relieve it. (Vitamin E will be applied to gums to help protect your gums during procedure).
I understand that this treatment CANNOT be used by pregnant or lactating women, people under the age of 18, people with gum disease, open cavities, leaking fillings, or other dental conditions, or people with a known allergy to peroxide and/or to aloe vera. I am not currently taking photo reactive drugs or have consulted with my physician about the use of an LED accelerator lamp with these treatments (Chlorthiazide, Hydrochlorothiazide, Chlorthalidone, Naprosyn, Oxaprozin, Nabumetone , Pirozicam, Doxycycline, Ciprfloxacin, Ofloxacin, Psoralens, Democlocyline, Norfloxacin, Sparfloxacin, Sulindac, Tetracycline, St. John’s Wart, Isotretinoin, Tretinoin). People that have had braces removed should wait for cement residue to wear off before getting a teeth whitening treatment and people with a piercing or other metal objects in the oral cavity should remove them before the treatment as they may turn black. If I feel a sharp pain on a particular tooth during the treatment I should stop the treatment and contact my dentist since this could be a sign of an open cavity.
I release Transform Beaute, LLC from all liability associated with this procedure. There are no guarantees for how long the cosmetic teeth whitening will last, results vary based on aftercare and individual lifestyle. Transform Beaute, LLC is not responsible for any technician errors. I understand that I have been advised to follow the aftercare protocol from my technician so as to avoid any discomfort or adverse side effects after the procedure has been completed.
This agreement will remain in effect for this procedure and all future Cosmetic Teeth Whitening procedures conducted by Transform Beaute, LLC. I understand that this agreement is binding and that I have read and fully understand all information above. I represent that I am over the age of 18 years.
Optional Photography Consent:
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I hereby grant Transform Beaute, LLC the full right to take, publish and reproduce photographs of me, my face, my eyes and/or eyelashes, both before and after this procedure, for any advertising, education, or other purposes whatsoever, including the right to retouch these photographs as deemed necessary. I further expressly assign any copyright in these photographs for any advertising or other purposes, along with any comments I may provide.
No, please do not use my photos
Signature
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Cosmetic Teeth Whitening Aftercare
THE WHITE DIET - After a Teeth Whitening Treatment, the pores of your enamel are open and this makes them extra vulnerable to any stains which can reverse a lot of the whitening benefit from your treatment. Follow the White Diet for 24- 48 hours after a Teeth Whitening service. Once the pores close, which usually happens within 24-48 hours after the procedure, you can resume your normal habits. An easy rule to remember is anything that would stain white fabric; Avoid it! Remember, the more staining your diet the faster you will re-stain your teeth. Taking care with what you eat will keep your smile whiter for longer.
NON-STAINING BEVERAGES: Water, Sparkling Water, Clear Liquids, Milk. BEVERAGES to AVOID: Fruit Juice, Tea and Coffee, Colas & Dark Liquids, Energy Drinks. NON-STAINING ALCOHOLIC DRINKS: Vodka, Gin, Tequila, White Wine, Champagne. ALCOHOLIC DRINKS TO AVOID: Red Wine, Dark Beer, Colored mixed drinks, Colored Cocktails, Dark Spirits.
FOOD YOU CAN HAVE: Chicken, Turkey, White Fish, White Rice, White Pasta, White Sauce, Cauliflower, Cottage Cheese, Potatoes, Bananas, Peeled Apples, White Chocolate. FOODS TO AVOID: Try to avoid foods with color. The more colorful, the more likely it can stain your teeth. Such as Colored fruits & vegetables i.e. Carrots and Orange Fruits and Vegetables - Broccoli, Spinach and Green Vegetables, Dark and Milk chocolate, Dark Breads, Tomatoes and Red Sauces such as Spaghetti Sauce, Soy Sauce, Beets, Berries, Butter and Margarine, Colored Candy.
ADDITIONAL INFORMATION: Avoid extremely hot or cold liquids. These are dangerous to your white smile because they change the temperature of your teeth. This temperature change (hot and cold cycling) causes teeth to expand and contract, allowing stains to penetrate your teeth. Try cutting down on these types of drinks (including coffee and tea) or try drinking them with a straw to reduce the amount of time they are in contact with your teeth.Avoid foods and drinks that are acidic. Acidic foods and beverages open up the pores of the tooth enamel allowing stains to more easily penetrate your teeth. Use a straw to help minimize the contact of these substances with your teeth.Cut back on drinking and smoking. Frequent consumption of alcoholic drinks and heavy smoking can reverse the effects of teeth whitening. Many alcoholic drinks such as wine have tannins that can stain the teeth. The same goes for the nicotine in tobacco. If you cannot quit drinking and smoking, at least try and reduce the frequency. Alcohol also reduces your resolve to avoid food which may stain your teeth. Use smudge-proof lipstick. Use smudge-proof lipstick to keep lipstick from getting on your teeth because regular lipstick can stain teeth. Also avoid tinted lip balm.
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