Informed Consent for Teeth Whitening

  • Teeth Whitening New Client Form

  • General Information:

  • Format: (000) 000-0000.
  • Date of your appointment:
     - -
  • Would you like to be added to our email list for specials and discounts?

  • Dental History:

  • Have you whiten your teeth before?*
  • Do you have any crowns, bridges, veneers, or fillings?*
  • Do you have sensitive teeth?*

  • Medical History:

  • Do you currently or have you had any of the following? Please check all that apply:
  • Are you pregnant?*

  • Lifestyle:

  • Do you use any of the following? Please check all that apply:

  • Informed Consent for Teeth Whitening:

  • General:*
  • Results Guarantee:*
  • Potential Risks: Although whitening treatments are generally safe. I understand that there can be potential complications of this treatment include, but are not limited to:*

  • 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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