Teeth Whitening Consent Form

Name: (first, last)
Age:
Date:

MonthDayYear
Date
Email:
example@example.com
Phone number:
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.
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.
Type a question

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

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

Clear
Date Signed

MonthDayYear
Date
your own Jotform It's free!
Should be Empty: