I certify that I am 18 years old for the 24k Gold treatment and 16 years old for the Blended Gel. Please read and sign.
The amount of whitening cannot be predicted or guaranteed. Teeth will not whiten past your genetic whiteness (what you were born with). Yellow or brown teeth with surface stains whiten more easily than gray or bluish teeth. Striped or spotted teeth are also difficult to whiten. This product should not be used on fillings, caps, veneers, etc.
This Teeth Whitening system uses a high-intensity 16% hydrogen peroxide whitening gel with an LED red/blue light, which activates the gel's components. This procedure may or may not require additional whitening to achieve your desired lightened shade. Two 15-minute sessions are included with your service price.
The Whitening Gel has adjusted Ph (acidity); however, teeth sensitivity may occur, and all teeth react differently. In the unlikely case sensitivity occurs, it may be present for 1-2 days. Stain Shields are available to help solve this concern. Scientific articles have shown that the materials used in teeth whitening are safe and effective. It does not change the structure of teeth; it merely helps to achieve a whiter and brighter look.
If the gel comes in contact with the gums, you may experience a slight tingling, and white bumps (blanching) can occur on the gums; these are not harmful in any way and will disappear in 1-2 days with normal saliva. All people's gums react differently to the whitening gel.
If you have fillings that are breaking down, decay in your teeth, erosion of the teeth, or exposed root surfaces due to periodontal disease, the gel will come in direct contact with these areas. It may cause sensitivity during and after treatment. This sensitivity will go away within 1-2 days; the Stain Shield will help this go away faster.
It is recommended that you visit your dentist should you have any concerns. Teeth whitening does not improve oral hygiene/health and is strictly cosmetic. Should underlying health issues, pre and post-existing, occur/become exasperated it is understood that these are beyond the natural scope of service and that Jesse Volpato will not be held liable for any issues that may result from using this product.
Guarantees:
The amount of whiteness varies with each individual. There are no guarantees to the degree of whitening.
Additional whitening sessions may be required to obtain the ultimate desired result.
Client Consent:
1. I have read and initialled this consent form and understand the risks and benefits explained on it. I understand it is impossible to state every risk or complication that may occur, but the technician has answered all my questions to my satisfaction.
2. I have had the opportunity to ask questions regarding this procedure.
3. I consent to treatment and assume all responsibility for the risks described above.