Beso Consent for Teeth Whitening 2022

Client's Name

Date

Please choose your Teeth Whitening Program:

"This information has been given to me so that I can make an informed decision about having my teeth whitened. I have the right to ask questions about any procedure before agreeing to undergo the procedure. I know that BESO MAKEUP, LLC or any of its employees are NOT dentists or doctors and CANNOT give any dental advise about Dental Treatment. I also acknowledge that BESO MAKEUP is NOT a dental office and BESO MAKEUP whitening process is for cosmetic reasons only and I will need to see my own dental provider if any issues or concerns would need to address by my own dental office."

Signature

1) Bleaching Trays: $200 for 2 arch ($100 for 1 arch)

-This method requires wearing custom-made whitening trays filled with a bleach solution to be worn by the client at home every day or every night for one or more weeks. When choosing this method I agree to whitening as directed in order to get the maximum bleaching results. The Bleaching Tray Kit comes with custom-made models of my teeth, bleaching trays, and 2 syringes of Bleach. In the event that I lose my kit or any of its' components I would need to pay in FULL for the kit again. I understand that I would ONLY be given 2 syringes in the initial appointment. Any additional bleach would need to be purchased SEPARATELY.

*I also understand that this procedure requires 2 appointments:

1) Impression Appointment (40 mins)

2) Delivery of Trays and Bleach (30 mins)

2) Light Whitening System: $280.00

- Uses 2 different types of Whitening lights in order to achieve whiter teeth.

- This procedure also requires Bleaching trays in order for patient to achieve best results and Bleach AT HOME.

*I also understand that this procedure requires 2 appointments:

1) Impression Appointment (40mins)

2) Use of UV Light & Delivery of Trays and Bleach (60 minutes)

3) BOOST: $400

- This method uses a hydrogen peroxide whitening gel to whiten the teeth. The gel is applied to your teeth in a series of 20 minute "sessions." The maximum number of sessions in one visit is 3. BESO MAKEUP will do 2 sessions.

*I also understand that this procedure requires 2 appointments:

1) Impression Appointment (30 mins).

2) BOOST in OFFICE TX: And Delivery of Trays and Bleach (90mins).

***When utilized properly, teeth whitening procedures and products whiten teeth, to one degree or another, in nearly all cases, with some whitening systems being more effective than others. As in any type of treatment or procedure, specific results cannot be guaranteed. Studies have shown that properly used whitening techniques and products will no harm your teeth or gums; however, there are certain inherent risks and limitations.

Signature - I understand that this appointment requires 2 appointments. At the 1st appointment the client must pay in full for the chosen procedure.

Risks to Teeth Whitening Procedures

Please Inital ALL Blocks Below

A) Tooth Sensitivity/Pain is NORMAL and usually mild, but it can be worse in susceptible individuals. Normally, pain subsides within 24 hours but in rare cases it can persist for longer periods of time. Individuals with existing sensitivity, recession, cracked teeth abfractions open cavities, leaking fillings or other dental conditions that cause sensitivity may find that those conditions worsen sensitivity or pain after treatment.

B) Gum/Lip/Cheek Inflammation may occur due to an inadvertent exposure of a small area of those tissues to the whitening materials. This is usually temporary but may persist for longer causing significant pain or discomfort.

C) Dry/Chapped lips are a common risk for in office procedures due tothe mouth being kept open by a plastic retractor for extended periods of time.

D) Cavities or leaking fillings that allow whitening produces to penetrate the tooth may cause significant pain when undergoing whitening treatments.

E) Cervical Abrasion/Erosion affects the roots of the teeth when the gums recede and they are characterized by grooves, notches, and or depressions, which appear darker than the rest of the teeth where the teeth meet the gums. These areas appear darker because they lack enamel. I understand that if this condition exists on my teeth these areas will be covered with a dental dam prior to whitening and will NOT Lighten.

F) Root Resorption is a condition where the root of the tooth starts to dissolve either from the inside or the outside. I understand that there is evidence that indicates the occurrence of this condition is higher in patients that have undergone a root canal followed by whitening procedures.

G) After whitening treatment, it is natural for the teeth to regress somewhat in their shading after treatment. This should be very gradual, but exposing the teeth to various staining agents can accelerate it. I understand that the results of my whitening program are NOT intended to be permanent, and secondary, repeat, or take-home treatments may be necessary to maintain the tooth shade I desire for my teeth.

H) Since it is impossible to state every complication that may occur as a result of your whitening program, the list of complications and risks in this form are incomplete. I understand that If I have more questions or concerns teeth whitening my personal dental professional can further explain the safety, efficacy, and potential risks or complications of whitening programs I choose to undergo.

**Exceptionally bleaching-resistant teeth: including, but not limited to tetracycline stained or fluoride stained teeth require longer treatment times than average cases, and in some cases require additional in-office whitening procedures. This is variable, and the time frame and number of necessary in-office visits cannot be known with certainty prior to the beginning of treatment. If the time necessary and the number of in-office whitening sessions are more than anticipated, additional charges may apply.

Please Inital ALL Blocks Below

1.) Spotting: Teeth with opaque spots, due to various causes, may result in the spots becoming noticeably lighter than the surrounding tooth color when whitened. Opaque spots will whiten much faster than the rest of the teeth, however effective whitening procedures will usually whiten the surrounding tooth structure enough that these spots are not readily noticeable to others.

2.) Dark Spots: Teeth with dark spots often respond well to more intense bleaching programs, however, there is always the possibility that the dark spots will not whiten to exactly the same color as the surrounding tooth.

3.) Discoloring at the gum line: All natural teeth have a different shade/color when comparing the gumline area to the tip of the tooth. After teeth whitening, a difference in color when comparing the gumline area of the tooth to the tips of the teeth will be apparent. The more effective the whitening technique that you select, the less this difference in color will be. However, regardless of technique, there will always be some difference in color from the gumline to the tip of the teeth.

1) I understand that whitening program results may vary or regress due to a variety of circumstances.

2) I have read and understand the above risks and complications and give my consent to my chosen whitening program.

3) I have given a complete and truthful medical history, including all medications, drug use, pregnancy, etc. I certify that I speak, read, and write English.

4) I have been given verbal and written instructions from my dental office staff as to how to prepare for my whitening program. All of my questions have been answered.

5) BESO MAKEUP staff has also the right to REFUSE Treatment for teeth whitening based on and not limited to: Poor Oral Hygiene, decay, cavities or any other medical/dental conditions that the clients may have.

6)I understand that BESO determines the cost of whitening programs, and they will inform me if there are any additional costs associated with my whitening program.

7)I understand that if I am pregnant l must consult with my physician before starting a whitening program.

To maintain the effectiveness of my whitening program, I will closely follow the instructions of my program and continue to wear my whitening trays as directed by the BESO Personnel. Without the prescribed maintenance, the whiteness of the teeth will fade with time.

It is important to understand that tooth-color fillings, bonding, porcelain veneers or porcelain crowns will not whiten like natural teeth, and may need to be replaced after teeth whitening if the color discrepancy is noticeable.

Signature

DISCLAIMERS:

1. I understand that bleaching/whitening materials only works on Natural untreated teeth; Meaning that bleaching will NOT whiten or work on Existing fillings, porcelain/metal crowns, implants, braces, veneers, and bonding.

2. I also understand that if my bleaching trays, models or bleach are lost, broken, damaged I will need to buy new materials again.

3. I also understand that BESO MAKEUP and Staff is NOT a dental or medical facility/office therefore, they CANNOT diagnose or give any medical advice.

4. I also understand that BESO MAKEUP staff are NOT doctors, dentist or medical staff and I understand that I am agreeing to whitening my teeth under my own liability and for cosmetic reasons only.

Name

First NameLast Name

Signature

You will receive a copy of post procedure instructions after your procedure is complete.

Most important aspect of Aftercare is following up with your dentist and dental provider for dental cleanings and routines checkups every 6 months.

1) Avoid Colored foods - The first 48 hours are CRUCIAL after ANY teeth whitening procedure because the teeth are more prone to blemishes at this time. If you want the BEST RESULTS and prolong your teeth whiteness, you must AVOID eating deep-colored meals and using tobacco. Items to avoid include wine, tea, coffee, cherries, chocolate, beets, all kinds of berries and dark sauces.

2) Avoid Acidic Foods - As part of your aftercare, you should avoid soda, pickles, lemons, pickles, limes and other foods or drinks containing acids. The teeth whitening treatment weakens the tubules, or pores, of teeth enamel and opens them up. The weakening of the enamel makes your teeth prone to stains and decay after whitening, and the

acid further worsens the weakness.

3) Foods You Can Eat 48 hours after the procedure, you can preserve teeth whiteness by eating these foods as part of aftercare. Certain meals help to clean and brush your teeth while eating, thus ensuring they remain white. Such meals include crunchy fruits or vegetables, especially apples, celery, carrots and green beans. They enhance the production and flow of saliva. Increased saliva helps clean the teeth and counteract the acids. The crunchy vegetables can remove temporary stains before they stick. However, if the fruit or vegetable is darkly colored, do not forget to wash your mouth with water afterward so that the colors will not stain your teeth.

4) Avoid Hot and Cold Meals -Your teeth will be sensitive after the whitening procedure. You should generally avoid meals that are either too hot or too cold. Buying toothpaste designed especially for sensitive teeth will help to reduce potential discomfort. It is advisable to avoid eating the wrong foods or drinks as much as possible. If the items have nutritional benefits, you can consume them, but you must rinse your teeth afterward or brush them. If brushing is not an immediate option, keep sugar-free gum handy to keep your teeth free of decay and prevent staining.

5) Enjoying Your New Smile - Depending on the type of teeth whitening procedure, your teeth should retain their whiteness for at least 6 months to a year or more depending on these factors and proper dental care. If you have questions, feel free to ask the BESO staff any questions OR consult your local dentist to address your concerns since BESO MAKEUP is NOT a dental office.

I hereby authorize Beso Makeup (Artist & Employees) to take photographs and/or videos of performed both before and after treatment, and I further authorize the use of said and/or videos to be used for the purpose of advertising.

I hereby authorize Beso Makeup (Artist & Employees) to take photographs and/or videos of performed both before and after treatment to be maintained only on file.

CLIENT SIGNATURE

DATE

Date

CLIENT PHONE NUMBER

Format: (000) 000-0000.

CANCELLATION POLICY:

We have a Strict Cancellation/Rescheduling/No Show Policy. We Ask That You Call, Cancel, Reschedule or Make Any Necessary Changes At Least 72 Hours Prior To Your Scheduled Appointment by phone (504)518-4461. Any Cancellations/Rescheduling made within 72 Hours prior to your appointment will Result in a 100% Cancellation Fee. If you are a NO SHOW this will result in a 100% Collection Fee. If Your Appointment is Cancelled by the Business, It May Be Due to Not Confirming Your Appointment (Via by phone and/or text message) or An Invalid/No Credit Card on File. PLEASE NOTE WEDNESDAYS (CLOSED) WILL NOT COUNT TOWARDS OUR STRICT 72 HOUR CANCELLATION POLICY.

Rescheduling Appointments Will Be Determined Upon Availability and May Result inAdditional Costs. **If you are in your first or last trimester of pregnancy, please contact us to reschedule your appointment. If you have received BOTOX treatment less than 30 days before your scheduled appointment, please contact us to reschedule your appointment* We Will NOT Be Ableto Service You If You're Running More Than 30 min Behind, Please Call Us to Reschedule your appointment by phone (504)518-4461. An Additional Late Fee of $50 WILL Be Applied if You Are More Than 15 Minutes Behind.

When booking with Beso Makeup an active Credit Card is required to be held on file to hold your appointment. Failure to provide a valid credit card at the time of booking will result in a cancellation of the appointment. If you Cancel/Reschedule and/or a No Show the Credit Card on file will be charged. If the payment does not go through you will not be able to reschedule and/or book another appointment until that payment is paid in full.

Customer Signature

Date

Beso Teeth Whitening Consent Form

BESO MAKEUP CLIENT PHOTO RELEASE FORM