Teeth whitening consent form
I agree that I am over the age of 18, am NOT under the influence of alcohol or drugs, am NOT pregnant or nursing and desire to receive the teeth whitening procedure. The general nature of the teeth whitening procedure has been explained to me.
Yes
I have been informed of the nature, risks, and possible complications and consequences of teeth whitening. I understand the teeth whitening procedure may have known or unknown complications including but not limited to: tooth sensitivity, tingling, minor discomfort, and toothache.
Yes
I understand that results may vary per client.
yes
I understand that the teeth whitening procedure is not intended to lighten artificial teeth, composite, crowns, veneers, caps, porcelain or other restorative materials
Yes
I understand that if I have multiple fillings, cavities, chips, or cracks in my teeth that the teeth whitening procedure is not best suited for me and I should seek an alternative non-bleaching option.
Yes
I understand that I may end up with multiple colorations or splotches due to various contributing factors.
Yes
I consent to my pictures being taken for before and after results.
Yes
I understand that this procedure is not permanent, and exposing teeth to various staining agents will result in changes of shade post bleaching.
Yes
I elect to receive this procedure from " SAMMY BEAUTY" of my own free will and understand and accept all of the above information.
Yes
Name
First Name
Last Name
Date
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Year
Date
Signature
Submit
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