Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health and Dental Information
Primary Dentist
Office Name
Office Address / Phone Number
When was your last cleaning or exam?
Were there any issues during this visit?
Do you have any known tooth decay or broken teeth?
Please Select
Yes
No
Do you have tooth filling or crowns?
Please Select
Yes
No
If so, do you have plans to have these replaced any time soon?
Have you had Professional Teeth whitening in the past?
Do you have any allergies?
If yes, then please specify it on the field above.
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.)
If yes, then please specify it on the field above.
Waiver and Consent
I voluntarily elect to undergo this treatment, having had the nature and purpose of teeth whitening, along with the risks associated.
The Smiling Face Co/ Technician has fully explained the procedure and I understand that there is a risk of side effects from this treatment including but not limited to; tooth Sensitivity, pain, tingling, headache, irritation to gums and possible damage to enamel.
I will advise the technician of any discomfort I may feel during the service and will not hold my Technician responsible for any pain or discomfort during or after treatment.
I fully understand that this service will not whiten porcelain crowns, or composite tooth colored bondings, like veneers, caps or bridges.
I understand that whitening is not recommended for people with gum disease, teeth with worn enamel or cavities, as this should be treated before undergoing treatment.
I understand that smoking and certain foods should be avoided to maintain results. Foods include; red wine, sports drinks, carbonated beverages ( dark), black tea and coffee, berries and strongly colored foods, as well as sauces such as soy, curry and tomato.
I confirm I am not pregnant or lactating.
I confirm that I am not under the influence of drugs or alcohol.
Waiver and Consent
This form is completely confidential. By signing below, agree to the following; I understand the information given pertaining t the requested treatment/s and confirm that I do not have any condition/s that would make the treatments unsuitable. I agree to inform my Technician if I experience any discomfort during the procedure, so they may adjust accordingly. I agree to waive all liability towards my Technician and The Smiling Face Co. for any injury or damages incurred due to any misrepresentation of my health, loose teeth, periodontal issues or any other Dental problems that they were not made aware of. I hereby give my consent and authorize The Smiling Face Co to provide Teeth Whitening Services to me today.
Signature of the Patient
Date Signed
-
Month
-
Day
Year
Date
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