Tooth Whitening Consent Form
Patient Information
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Health and Dental Information
Toothpaste Brand
Are you using Dental floss in cleaning your teeth?
Please Select
Yes
No
Are you using braces?
Please Select
Yes
No
Do you have tooth filling?
Please Select
Yes
No
Do you have any known tooth decay or broken teeth?
Please Select
Yes
No
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 authorize Jaluxury Beauty to perform this procedure to me. The technician explained the nature of the treatment and how it will help me.
I understand the risk and complications if I do not follow the instructions given to me after the procedure which involves post-treatment and follow-ups.
I release Jaluxury Beauty for any responsibility in case of an accident, illness, or injury.
I acknowledge that all information I provided int his form is true and accurate.
Signature of the Patient
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: