Informed Consent for Teeth Whitening

Teeth Whitening New Client Form
General Information:
Name:*

First NameLast Name
Phone:*
Format: (000) 000-0000.
Date of your appointment:

MonthDayYear
Date
Email:
example@example.com
YesNo
How did you hear about BeeBrightStudio?
Dental History:
YesNo
If yes, please state when?
YesNo
If yes, please state where?*
YesNo
When was your last dental visit?
Medical History:
Bleeding GumsTooth DiscolorationDental TraumaSores in MouthUntreated Dental IssuesNone
YesNo
Are you currently taking any medication? If yes, please explain:
Any known allergies ? If yes, please list:
Lifestyle:
TeaCoffeeDark SodasRed WineTobacco Products
Informed Consent for Teeth Whitening:
I understand that I am participating in a professional teeth whitening procedure that is designed to lighten the color of my teeth.I understand that the teeth whitening procedure uses a specially designed LED lamp in order to accelerate the whitening process.
I understand that people with yellowish teeth generally get the best results and that if my teeth have spots due to tetracycline use (grayish tint) or fluorosis, these will be difficult to whiten.I understand that although most natural teeth can benefit from a teeth whitening, everyone’s teeth are different and that results will vary.I understand that results vary and that I may need multiple treatments to achieve the results I want.I understand that if I have artificial teeth, caps, crowns, veneers, porcelain, composite or other restorative materials, I shouldn’t expect dramatic results from this treatment because the peroxide gel will not whiten (or damage) artificial dental work.I understand that my teeth will never be whiter than the white color my genes naturally allow.I understand that the results of the whitening treatment are not intended to be permanent and that touch-up appointments every 3-4 months are recommended to maintain the shade I desire for my teeth.
I understand that gum/lip irritation can happen if the whitening gel comes in contact with gum tissue or lips during the treatment and that it may cause inflammation or whitening of these areas. I understant that some tingling or stinging sensation on these soft tissues can happen during the treatment if any gel comes in contact with them. (This is transient and will reverse in about 10-30 min).I understand that while some tooth sensitivity is normal and should only last the first 24 hours after the whitening treatment the following may make teeth more sensitive after treatment: (existing sensitivity, damaged or missing enamel, tooth recession, cracked teeth, exposed dentin, cavities, exposed root surfaces, leaking fillings, severely worn teeth).I understand white spots or streaks may happen on my teeth due to calcium deposits that naturally occur in teeth and that these spots are NOT caused by the peroxide gel. These spots diminish in about 3-4 days.I understand that it is natural for teeth to regress after treatment and that exposing the teeth to various staining agents such as dark-colored liquids (coffee, tea, dark sodas), all tobacco products, mustard or ketchup, red wine, soy sauce, berries, and red sauces can stain my teeth again.
I understand that this procedure should NOT be administered on me if I am pregnant, nursing, have not seen a dentist in two years, have unfilled cavities in my teeth, have a temporary crown, or have untreated gum disease.
Oversight and Documentation
- I understand that the cosmetic teeth whitening services are performed under the oversight of a licensed dentist who reviews and supervises treatment protocols.
- I give my consent for before-and-after photos of my teeth to be taken and submitted to the overseeing dentist for review and quality assurance purposes.
- These images are used solely for professional documentation, supervision, and training, and will not be shared publicly without my written consent.
Photo Request:
Please provide us with a clear before photo of your teeth prior to your appointment. This helps us track your progress and ensures proper documentation for oversight by our supervising dentist.
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Consent and Acknowledgment

By signing below, I confirm the following:
- I have completed this form truthfully and to the best of my knowledge.
- I agree to notify the technician of any changes to the information provided.
- I confirm that I do not have any condition(s) that would make the requested treatment inappropriate.
- I will promptly inform the technician of any discomfort experienced during the procedure so adjustments can be made as needed.
- I waive all liability against the technician for any injury or damages resulting from any misrepresentation or omission regarding my health.
Disclaimer: This cosmetic teeth whitening service is not intended to diagnose, treat, or cure any dental conditions and is not a substitute for professional dental care. Clients are responsible for maintaining regular dental checkups and must disclose any changes in their oral health prior to each appointment.
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Teeth Whitening New Client Form

General Information:

Dental History:

Medical History:

Lifestyle:

Informed Consent for Teeth Whitening: