Teeth Whitening Informed Consent Form
Procedure Details
Do you have any allergies?
If yes, then please specify it on the field above.
Have you had teeth whitening before?
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Yes
No
Are you currently taking any medications?
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If yes, then please specify it on the field above.
Do you have any crowns, bridges, veneers, or fillings?
Yes
No
If yes, please explain
Other
Do you have sensitive teeth?
Yes
No
When was your last dental visit?
Please explain
Other
Do you currently or have you had any of the following? Please check all that apply:
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Bleeding gums
Trauma
Genetic disorder
Sores in mouth
Tooth discoloration
Untreated dental issues
If yes, please explain:
Other
Are you pregnant and/or breast feeding?
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Yes
No
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.
Lifestyle
Do you use any of the following? Please check all that apply:
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Coffee
Tea
Dark sodas
Tobacco products
Red wine
Other
Acknowledgment and Waiver
Informed Consent Form
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I understand that teeth whitening is a cosmetic procedure designed to bleach the stains on the surface of my teeth and will not change my natural enamel colour and will only bleach the stains on the surface of the tooth enamel.
I understand the process will involve peroxide gel being used on the surface of my teeth.
I understand that teeth whitening will not be beneficial on stains and discolouration inside the tooth enamel.
I understand that teeth whitening treatments are not intended to lighten the following types of teeth: Artificial teeth, Caps, Crowns, Veneers, Porcelain, Composite, Other restorative materials
I understand that the results of my whitening are not guaranteed and results vary.
I understand that although my technician has been trained in the proper use of the in-office whitening system they are not a dental practitioner and the treatment is not without risk. I understand that some of the potential complications of this treatment include, but are not limited to:
I understand that teeth with the following may not lighten and are usually best treated with other non-bleaching alternatives.
I understand that teeth with the following may not whiten or be improved as well and may need multiple treatments or may not whiten at all.
I understand that while some tooth sensitivity is normal and should only last for a few days, the following may make my teeth more sensitive after the treatment and may make the sensitivity last longer:
Artificial teeth
Caps
Crowns
Veneers
Multiple colorations
Bands
Splotches
Existing sensitivity
Tooth recession
Exposed dentin
Exposed root surfaces
Severely worn teeth
Multiple fillings
Cavities
Blisters
Tooth Sensitivity or discomfort
Porcelain
Composite
Other restorative materials
dark shadows due tetracycline use etc.
White spots due to Fluorosis
Teeth with a dead nerve
Damaged or missing enamel
Cracked teeth
Cavities
Leaking fillings
Chips
Cracks
Fluorosis enhancement
Gum irritation
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 holes in my teeth, have a temporary crown, or have untreated gum disease.
I understand that it is natural for teeth that underwent the whitening treatment to regress somewhat in their shading posttreatment. I understand that this is natural and should be very gradual but it can be accelerated by exposing the teeth to various staining agents such as dark-colored liquids (coffee, tea, dark soda), all tobacco products, mustard or ketchup, red wine, soy sauce, berries, berry pie, and red sauces like tomato sauce.
I understand that the results of the whitening treatment are not intended to be permanent.
I understand that repeat or take-home treatments may be needed further to maintain the whitening result.
I understand that after treatment, I will be required to refrain from consuming any substances that could discolor my teeth for the first 24 hours after treatment. These substances include but are not limited to dark-colored liquids (coffee, tea, dark soda), all tobacco products, mustard or ketchup, red wine, soy sauce, berries, berry pie, and red sauces like tomato sauce.
I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment has been explained to me. I understand and acknowledge that there are risks involved with the treatment I will be receiving. Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications, and I have had the opportunity to ask questions regarding these risks and other possible complications.
GENERAL: Most natural teeth can benefit from a teeth-whitening treatment, I understand that everyone’s teeth are different and that results will vary. I understand that people with yellowish teeth generally get the best results and that if my teeth have spots due to tetracycline use (greyish tint) or fluorosis, these will be difficult to whiten. Also, 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. Also, I am aware that my teeth will never be whiter than the white colour my genes naturally allow. Potential risks although whitening treatments are generally safe, I understand that some of the potential complications of this treatment include, but are not limited to.
GUM/LIP IRRITATION: Whitening gel that comes in contact with gum tissue or the lips during the treatment may cause inflammation or whitening of these areas. This is due to inadvertent exposure of small areas of those tissues to the whitening gel. The inflammation and/or whitening of gums and lips is transient, and the colour change of the gum tissue should reverse within 30 minutes. I may feel a stinging and tingling sensation on these soft tissues during the treatment if the gel comes in contact with them.
TOOTH SENSITIVITY: Although uncommon, some customers can experience some tooth sensitivity during the first 24 hours after the whitening treatment. People with existing sensitivity, recently cracked teeth, micro-cracks, open cavities, leaking fillings, exposed roots, or other dental conditions that cause sensitivity may find that those conditions increase or prolong tooth sensitivity after the treatment.
SPOTS OR STREAKS: Some customers may develop white spots or streaks on their teeth due to calcium deposits that naturally occur in teeth. The peroxide gel does NOT cause these spots. The gel just brings the already existing calcium deposits out and makes them visible again. These usually diminish over time.
RELAPSE: After the treatment, it is natural for teeth' colour to regress somewhat over time. This is natural and should be very gradual, but it can be accelerated by exposing the teeth to various staining agents, such as coffee, tea, tobacco, red wine, colas, etc. I realize that I should not eat or drink anything except water for 60 minutes after the treatment because the gel opens the pores of my enamel and makes my teeth very vulnerable to staining agents. I understand that the results of the treatment are not intended to be permanent and that secondary, repeat or touch-up treatments may be needed for me to maintain the colour I desire for my teeth.
ELIGIBILITY: I understand that this treatment CANNOT be used by pregnant or lactating women, people under the age of 16, people with gum disease, open cavities, leaking fillings, or other dental conditions, or people with a known allergy to peroxide and/or to aloe vera. I am not currently taking photoreactive drugs or have consulted with my physician about the use of an LED accelerator lamp with these treatments (Chlorthiazide, Hydrochlorothiazide, Chlorthalidone, Naprosyn, Oxaprozin, Nabumetone, Piroxicam, Doxycycline, Ciprofloxacin, Ofloxacin, Psoralens, Democlocyline, Norfloxacin, Sparfloxacin, Sulindac, Tetracycline, St. John’s Wart, Isotretinoin, Tretinoin). People that have had braces removed should wait for cement residue to wear off before getting a teeth whitening treatment and people with a piercing or other metal objects in the oral cavity should remove them before the treatment as they may turn black. If I feel a sharp pain on a particular tooth during the treatment I should stop the treatment and contact my dentist since this could be a sign of an open cavity.
By signing this document, I indicate that I am not ineligible as per the criteria listed above, that I have read and fully understand this entire document including the possible risks, complications and benefits that can result from the treatment, and that I am performing this treatment under my own responsibility and will not hold TheBestYou100, its owners, suppliers or any of its employees liable for any of the above risks that I may experience. I also certify that I have healthy teeth and gums.
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