Teeth Whitening Consent Form

Name: (first, last)

Age:

Date:

Date

Email:

example@example.com

Phone number:

Format: (000) 000-0000.

Address

Street Address

State / Province

Toothpaste Brand

Are you using Dental floss in cleaning your teeth?

Do you have any known tooth decay or broken teeth?

Do you have any allergies?

Are you currently taking any medications?

If yes, then please specify it on the field above.

Do you have any medical conditions that we should be aware of? (Communicable disease, cardiovascular problems, diabetes, etc

Type here

If yes, then please specify it on the field above.

I Iauthorize (The Nail Hive ) to perform this procedure to me. explained the nature of the treatment.

I release The Nail Hive for any responsibility in case of an accident, illness, sensitively, gum irritation or injury.I acknowledge that all information I provided int his form is true andI will use white color toothpaste,I aware that I may have side effects and I may need more than one session

Signature of the Patient

Date Signed

Date

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