TEETH WHITENING CONSENT FORM

BEFORE COMING IN DRINK A TYNOL
BRUSH YOUR TEETH E A T
BEFOREHAND.

WATER WILL BE YOUR BEST-FRIEND FOR THE NEXT 24 HOURS.

NO FOOD FOR THE NEXT 2 HOURS

IF YOU FEEL SOME SENSITIVITY HYDRATE AND DRINK SOME IBUPROFENS.

IF YOU CHOOSE TO DRINK COFFEE WHILE THE 2HRS IS UP YOU MAY DRINK WITH A STRAW & SWISH W WATERIMMEDIATELY.
ABSOLUTELY NO RED SAUCES OR DRINKS OF ANY KIND NO DARK COLORED FOODS SUCH AS SPAGHETTI, PIZZA & SPINACH KETPCHUP MUSTARD.

NAME

First NameLast Name

Preferred pronouns

how did you hear from me

Instagram

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Do you have the following: Artificial teeth, * caps, crowns, veneers, porcelain, composite or other restorative materials? If so, what? please let your technician know

Have you had a dental clean? How long ago?

Are you due for dental work? If so, what?

Are you pregnant OR breast feeding?

Sensitive teeth

Do you grind your teeth?

Are you allergic to peroxide?

Do you smoke?

Do you suffer from cold sores?

Have you had cosmetic injections/filler or botox in the last 4 weeks?

acknowledge that I am having a teeth whitening treatment that is designed to whiten the color of my teeth. 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 (grayish 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. I am aware that my teeth will never be whiter than the white color my genes naturally allow.TO CONSENT; SIGN FULL NAME BELOW

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 color 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. TOCONSENT ; SIGN FULL name

I UNDERSTAND after the treatment, it is natural for teeth color 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 color I desire for my teeth. *TO CONSENT; SIGN FULL NAME BELOW

Eligibility: I understand that this treatment cannot be used by pregnant or lactating women, 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 (chlorothiazide, hydrochlorothiazide, chlorthalidone, naprosyn, oxaprozin, nabumetone, piroxicam, doxycycline, ciprofloxacin , ofloxacin, psoralens, demeclocycline , norfloxacin, sparfloxacin, sulindac, tetracycline, st. john's wort , 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.TO CONSENT; SIGN FULL NAME BELOW

TEETH WHITENING MINUTES

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 onadaily1x (alma castro) it's owners,. suppliers or any of it's employees liable for any of the above risks that I may experience. I also certify that I have healthy. teeth and gums.

TEETH WHITENING FORM