Teeth-Whitening Consent
Cosmetic Whitening
Please answer the following
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date
-
Month
-
Day
Year
Date
Have you had Teeth-Whitening before?
Yes
No
If Yes, when was you last treatment?
Do you have sensitive teeth?
Yes
No
Do you have any known cavities or cracks in your teeth?
Yes
No
Do you floss on a daily basis?
Do you have sensitive gums?
Do you use at home whitening kits/strips?
You understand that this treatment may cause some sensitivty to the teeth or gums?
You understand that it may take several treatments to get to your desired shade.
You understand that 24hours after your treatment your teeth are very porous and eating or drinking anything dark or colorful will stain your teeth and should be avoided.
You understand that this is not a permanent treatment. Additional treatments will be required to up keep the brightness of your results.
You understand that your technichian is not a licensed dentist and will not be held responsible for prior problems you may have with your teeth.
By agreeing to this consent, you acknowledge all of the above answers and descriptions are truthful to the best of your ability. You will not hold Poise Beauty Bar accountable for any harm that may be caused due to lack of communication or wrongly answered questions. You have made you technichian aware of any and all potential things that may cause this treatment to not work properly or cause harm to you.
Signature
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