Teeth Whitening Consent Form
Client Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Please list any allergies:
Have you ever had an adverse reaction to:
Hydrogen Peroxide
*
Yes
No
Peppermint
*
Yes
No
Vitamin E
*
Yes
No
Baking Soda
*
Yes
No
Have you recently had any dental restorations placed? (Crowns, bridges, fillings, implants or partial dentures)
Are you scheduled or anticipating restoration work in the next 6 months?
Have you recently had oral surgery?
When was your last dental cleaning (approx.)?
Have you used whitening products in the past? If yes,
Did you see any results?
Did you have any negative side effects? (Sensitivity, chemical irritation, brunt tissues)
Do you suffer from areas of recession or sensitive gums?
Are you pregnant or nursing?
Do you suffer from diabetes or epilepsy?
Before and after pictures are always completed with our treatments, do we have your permission to post your pictures to social media and website for educational purposes?
*
Yes
No
Client Consent
The amount of whitening cannot be predicted or guaranteed. Teeth will not whiten past your genetic whiteness (what you were born with). Yellow or brown teeth with surface stains whiten easier then grey or bluish teeth. Striped or spotted teeth are also difficult to whiten. Fillings, crowns or veneers will whiten back to the
*
I have read and understand the statement above.
The teeth whitening gel uses hybrid (5% Hydrogen Peroxide and 20% Carbamide Peroxide) high intensity bleaching gels and a high density cold blue light, which activates the gel's components. This procedure may or may not require additional whitening in order to achieve your desired lightened shade.
*
I have read and understand the statement above.
The teeth whitening gel has adjusted PH (acidity) and conditioners to reduce teeth and gum sensitivity, all teeth react differently. In the unlikelihood sensitivity occurs, it may be present for 1-2 days. Scientific articles have shown that the materials used in teeth whitening are safe and effective. It does not change the structure of teeth; it merely helps to achieve a whiter and brighter look.
*
I have read and understand the statement above.
The teeth whitening gel has conditioners and moisturizers in it to soothe the gums. If the gel comes in contact with them, tingling and white bumps (blanching) can occur on gums; these are not harmful in any way and will disappear in 1-2 days with normal saliva. All people's gums react differently to the whitening gel.
*
I have read and understand the statement above.
If you have fillings that are breaking down, decay in your teeth, erosion of the teeth, or exposed root surfaces due to periodontal disease, the gel will come in direct contact with these areas and may cause sensitivity during and after treatment. This sensitivity will go away within 1-2 days.
*
I have read and understand the statement above.
Guarantees:
The amount of whiteness varies with each individual. There are no guarantees to the degree of whitening.
*
I have read and understand the statement above.
We guarantee change, but cannot guarantee how much.
*
I have read and understand the statement above.
Additional whitening sessions may be required to obtain the ultimate desired result.
*
I have read and understand the statement above.
Signature of the Client
Date Signed
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: