Teeth Whitening - Client History, Release & Consent Form
Hannah Davis Lashes
First & Last Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
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example@example.com
Mobile Phone Number
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Please enter a valid phone number.
Date of birth
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-
Month
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Day
Year
Date
Are you currently pregnant or breastfeeding?
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Pregnant
Breastfeeding
Neither
Please list any relevant allergies you have (such as to aloe vera, vitamin E or to peroxides):
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Do you currently have any cold sores or open sores on or in your mouth area?
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Yes
No
To your knowledge, do you currently have any cavities?
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Yes
No
Unsure
Have you had braces removed in the last 6 months?
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Yes
No
Have you had a dental cleaning in the last 6 months to a year?
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Yes
No
Do you have any piercings in your mouth?
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Yes
No
Are you currently taking any medications such as Acne medication, Antidepressants, Antipsychotics, Diuretics, Hypoglycaemic, or NSAIDS?
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Yes
No
If you answered "Yes" to the question above please state which medications you are on and if these medications have led you to experience photosensitivity/hyper-pigmentation.
In the front of your mouth, the area you see when you smile with your teeth, do you have any porcelain/ceramic materials (i.e crowns, veneers, bridges, implants) or tooth fillings?
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Yes
No
Unsure
Have you ever cosmetically whitened your teeth before?
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Yes
No
If you answered "Yes" to the question above when did you last have your teeth cosmetically whitened?
Do you have sensitive teeth and/or gums or have you experienced sensitivity in your teeth and/or gums?
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Yes
No
If you answered "Yes to the question above please further explain your sensitivity issues.
By checking "Yes, I understand, agree and accept" I acknowledge that I am purchasing a teeth whitening treatment that is designed to whiten the colour of my teeth, as a part of the purchase, I am asking for assistance in the whitening process of my teeth. RESULTS GUARANTEE: Although most natural teeth can benefit from a teeth whitening treatment, I understand that everyone’s teeth are different and that results will vary/I understand that people with yellowish teeth generally get the best results, and that if my teeth have spots due to tetracycline use (greyish tint) or fluorosis, these will be difficult to whiten. Also, if I have artificial teeth such as caps, crowns, veneers, porcelain, composite, or other restorative material, I shouldn’t expect dramatic results from this treatment because the peroxide gel will not whiten (or damage) artificial dental work. Also, I am aware that my teeth will never be whiter than the white colour my genes naturally allow.
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Yes, I understand, agree and accept
By checking "Yes, I understand, agree and accept" I acknowledge the POTENTIAL RISKS associated with Teeth Whitening. Although whitening treatments are generally safe, I understand that some of the potential complications of this treatment include, but are not limited to: GUM/LIP IRRITATION: Whitening gels that come in contact with gum tissue or the lips during the treatment may cause inflammation or whitening of these areas. This is due to inadvertent exposure of small areas of those tissues to the whitening gel. The inflammation and/ or whitening of the gums and lips are transient, and the colour change of the gum tissue will reverse within 30 minutes. I may feel a stinging and tingling sensation on these soft tissues during the treatment if the gel comes in contact with then. TOOTH SENSITIVITY: Although uncommon, some people can experience some tooth sensitivity during the first 24 hours after the whitening treatment. People with existing sensitivity, 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. SPOTS OR STREEKS: Some people may develop white spots or streaks on their teeth due to CALCIUM DEPOSITS that naturally occur in the teeth, these spots are NOT caused by peroxide gel. The gel just brings the already existing calcium deposits out and makes them visible again. These usually diminish over time. RELAPSE: After the treatment it is natural for teeth colour to regress somewhat over time. This is natural and should be very gradual, but it can be accelerated by exposing the teeth to various staining agents, such as coffee, tea, tobacco, red wine, pop, etc., I realize that I should not eat or drink anything except water 90 minutes after the treatment because the gel opens the pores of my enamel and makes my teeth very vulnerable to staining agents. Only 24 hours after I conclude the treatment can I resume my normal habits. I understand that the results of the treatment are not intended to be permanent and that secondary, repeat or touch-up treatments may be needed for me to maintain the colour I desire for my teeth.
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Yes, I understand, agree and accept
By checking "Yes, I understand, agree and accept" I understand this treatments ELIGIBILITY: I understand that this treatment CANNOT be used by pregnant or lactating woman, people under the age of 16, 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. People that have had braces removed should wait 6 months 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 a cavity. I am aware that I am not in a dental office and that the staff here present is neither dentists or health professionals. We do not offer any advice on oral health. It is important to visit you dentist on a regular basis. I understand that liability is limited to the amount paid for my teeth whitening product and that the management, staff of this establishment assume no liability of any kind. I understand it is recommended that I visit my dentist if I experience any problems after using the teeth whitening products. By signing this document, I indicate that I am not ineligible as per the criteria listed above, that I have read and fully understand this entire document including the possible risks, complications and benefits that can result from the treatment, and I am performing this treatment under my own responsibility. I also certify that I HAVE HEALTHY TEETH AND GUMS.
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Yes, I understand, agree and accept
By checking “Yes” you give your consent to allow the technician performing your service to take photos/videos of your teeth and/or yourself. By checking “No” you decline consent, therefore not allowing the technician performing your service to take any photos/videos of your teeth and/or yourself. Photos/videos are taken for promotional purposes and to show the before and after results only. Photos/videos taken during your service may or may not be posted on our social media platforms displaying the contents of this service.
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Yes
No
What is the current date you are filling out this form?
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Month
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Day
Year
Date
By signing here you are acknowledging that you agree, understand, and accept the contents of this form. You also acknowledge that you are giving permission to allow a minor to have the service of Cosmetic Teeth Whitening done. (Please sign below - Parent or guardian if under 18 years of age.)
By signing here you are acknowledging that you agree, understand, and accept the contents of this form (Please sign below - Individual having the service done.)
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Submit
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