Teeth Whitening Consent Form

Teeth Whitening Consent Form

You may feel a light tingling or minor blanching of the gums, this is normal and will usually disappear in less than 4 hours. Your teeth will never be whiter than your genetic traits. White spots may appear if you had braces, or have porous enamel, this will usually disappear in 8 hours. The whitening gel is PH neutral and will not damage your enamel, caps crowns, or veneers. Please be advised, your teeth can only be whitened to a certain shade and cannot go whiter than your genetic traits allow.
I have read and agree to the terms above*

Acknowledge
Exclusions for Treatment

If you select any of the below questions or if you have not had a dental cleaning in the last 6 months please consult your dentist prior to use
Please select all that apply*

I have allergies or reactions to any ingredients in the gelI have existing tooth decay, periodontal disease, or gingivitisI am photosensitive or on photosensitive medicationsI am pregnant or breastfeedingI am under the age of 18I have had oral surgery or extractions within the last 30 daysI am wearing oral piercings (remove prior to use)None of the above
Aftercare & Follow Up

For the first hour after use drink only water. Avoid any staining food or drinks for the first 24 hours. Please review the caution statement on the in-office and home kit prior to use.
In consideration of the services provided, I hereby release Glow Up Tanning, LLC and its employees, distributors, and/or dealers from all manner of actions, and causes of action, which may arise from the use of any product(s), or service(s) provided.*

Agree
I, First Name Last Name and I, First Name Last Name have been advised to consult a dentist before initial treatment. I have read the above and certify that I have healthy teeth and gums.
Client 1 Signature*

Clear
Client 2 Signature*

Clear
Should be Empty:

Teeth Whitening Consent Form

Exclusions for Treatment

Aftercare & Follow Up