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
Would you like to be added to our email list for specials and discounts?
How did you hear about Smiles by Alicia?
Dental History:
Have you whiten your teeth before?
If yes, please state when?
Do you have any crowns, bridges, veneers, or fillings?
If yes, please state where?
Do you have sensitive teeth?
When was your last dental visit?
Medical History:
Do you currently or have you had any of the following? Please check all that apply:
Are you pregnant?
Are you currently taking any medication? If yes, please explain:
Any known allergies ? If yes, please list:
Lifestyle:
Do you use any of the following? Please check all that apply:
By signing below, I agree to the following: I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information I agree that do not have any condition(s) that would make the requested treatment unsuitable will inform the technicion of any discomfort may experience to allow them to adjust accordingly. I agree to waive all liability toward my technician for any injury or damages incurred due to any misrepresentation of my health.
Name Printed
signature
Date

MonthDayYear
Date
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:
Eligibility:
Name Printed
Signature
Date

MonthDayYear
Date
Should be Empty:

Teeth Whitening New Client Form

General Information:

Dental History:

Medical History:

Lifestyle:

Informed Consent for Teeth Whitening: