Teeth Whitening Consent Form

Please complete this form as accurately as possible. IT WILL TAKE YOU 10 MIN OR LESS BUT SAVE YOU TIME AT YOUR APPOINTMENT. This information will be needed for safe and proper care at VIP Health and Laser. Information will be sent by electronic encryption and will be placed into secure medical records. After you sign, you will be directed to the appointment page. Thank you!

Tooth whitening is done using a double tray prefiiled with carbamide and hydrogen peroxide enhanced with LED lighting. This is able to penetrate deep to bleach the teeth multiple shades whiter. Sensitivity may occur, and we advise flossing daily and brushing with Sensodyne Pronamel brand toothpaste twice daily

Contraindications:

You may not have tooth whitening in these circumstances:

Pregnancy
Lactation
Allergy to bleaching agents
Bronchial asthma
Cancer
Dental Cavities
Gum disease
Hypersensitivity of teeth
Teens or children under 14

Today's Date*

MonthDayYear

SECTION 1: PERSONAL INFORMATION

Full Name*

First NameLast Name

Patient Date of Birth*

MonthDayYear

Email*

example@example.com

Phone Number*

Area CodePhone Number

Emergency Contact*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How did you hear about us?

SECTION 2: HIPAA FORM

HIPAA Notice of Privacy Practices

This is a notice required by HIPAA (Health Insurance Portability and Accountability Act of 1996) that explains how we at VIP Health and Laser keep your information private. It explains how we use, share, and protect your health information. This notice explains your privacy rights. After reviewing this form, sign below to acknowledge that you have received this form. You may contact us at any time if you have questions about this form or wish to have it in writing.

Protected Health Information (PHI) submitted to us via web forms is encrypted during storage and transmission on HIPAA compliant servers and held in strictest confidence. We do not give out, exchange, barter, rent, sell, lend, or disseminate any information about applicants or clients who apply for or actually receive our services. Any information you send or communicate to us is considered confidential and is specifically restricted by a patient/client-healthcare provider relationship. You may request that we communicate in an alternative confidential manor.

PHI may be used for treatment of health conditions. We perform care evaluations using history and physical exams to offer options for treatment. PHI may be used in a minimally necessary fashion for payments, billing, marketing, and for training of staff. PHI may be used to help you find health services and benefits to achieve your health goals.

We may receive requests from authorities or government agencies to disclose PHI if it necessary to convict a criminal. PHI may be used by government authorities to help avoid or resolve a threat to public health or safety. The Food and Drug Administration may request PHI regarding product recalls or to report adverse events. PHI may be used as required by law to report cases of abuse or neglect.

You have the right to receive a copy of your health records. You have the right to inspect, review, and receive a copy of your medical records and billing records. You may request to add a correction to your health information.

We may use before and after photos to show treatment benefits to other clients or potential clients. In these cases we cover eyes and identifying body features. We do not provide PHI with any photos. A separate consent form will need to be signed by you to allow this.

To file a complaint if you think your privacy rights have been violated, you can report it to U.S. Department of Health and Human Services Office for Civil Rights. You can request a copy or view a copy of this at any time in our “Terms” on our website, viphealthandlaser.com. If any of this is unclear you have the right to have us explain this to you at any time.

Choose One*

I ACKNOWLEDGE THAT I HAVE RECEIVED THIS HIPAA PRIVACY STATEMENT. THIS DOES NOT MEAN THAT YOU HAVE AGREED TO ANY SHARING OF YOUR PROTECTED HEALTH INFORMATION.I REFUSE TO ACKNOWLEDGE THAT I HAVE RECEIVED THIS HIPAA PRIVACY STATEMENT. REFUSING DOES NOT PREVENT US FROM USING OR DISCLOSING PHI AS HIPAA PERMITS. WE ARE ONLY REQUIRED TO DOCUMENT IT.

Toothpaste Brand

Are you using Dental floss in cleaning your teeth?*

Are you using braces?*

Do you have tooth filling or fillings?*

Do you have any known tooth decay or broken teeth?*

Do you have any allergies?*

If yes, then please specify in the field above.

Are you currently taking any medications?*

If yes, then please specify in 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 in the field above.

SECTION 3: WAIVER AND CONSENT

I allow VIP Health and Laser staff to administer the tooth whitening treatment and I understand the possible side effects of the tooth whitening products given to me.

I understand the risk and complications if I do not follow the instructions given to me after the procedure which involves flossing and brushing twice daily with Sensodyne Pronamel brand toothpaste. If a side effect occurs, I may need to have post-treatment measures and follow-ups.

I assure that I am not under 14 years of age, pregnant, lactating, have an allergy to bleaching agents, have bronchial asthma, have cancer, have cavities, have gum disease, and/or have hypersensitivity of teeth.

I release VIP Health and Laser for any responsibility in case of an accident, illness, or injury. I acknowledge that all information I provided in this form is true and accurate.

I acknowledge that all information I provided in this form is true and accurate.

I CONSENT TO A TREATMENT COURSE OF TOOTH WHITENING.I DO NOT CONSENT TO TOOTH WHITENING.

FINAL SECTION 5B: PHOTO CONSENT

Consent for Photographs and Videos

I consent to allow personnel of VIP Health and Laser to take photographs and videos during the course of my therapy. Photos and videos may be used for showing the benefit of the procedures done at VIP Health and Laser to other clients or potential clients. The photos and videos may be used for social media channels, for documenting before and after results, for medical education, to offer other clients options and/or for the professional evaluation of treatment progress. You may request that the photos and videos not show your identity (cover eyes and/or face) by selecting below. Names are never provided with photos and videos but comments on the photos and videos are possible by viewers or outside parties.

Choose one*

I CONSENT TO ALLOW PHOTOGRAPHS AND VIDEOS AS DESCRIBED ABOVEI DO NOT CONSENT TO ALLOW PHOTOGRAPHS OR VIDEOS.

FINAL SECTION 5C: EMAIL CONSENT

Consent for Email Communication

I consent to allow personnel of VIP Health and Laser to communicate information with encrypted email including but not limited to appointment reminders and laser therapy instructions. I consent to receive email at any email address that I provide to VIP Health and Laser. We may send you email up to 3 times weekly to provide notification about VIP Health and Laser services. Please note that we only send email by TLS encryption security protocol. If you opt out of email, it may be more inconvenient to receive services from us. There are risks with using email communication such as wrong address, forgery, phishing or use without authorization.

Choose one*

I CONSENT TO ALLOW EMAIL COMMUNICATION.I DO NOT CONSENT TO ALLOW EMAIL COMMUNICATION.

Message / Comments - Add photo or other important information here as desired (Optional).

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Review your information above to make sure it is complete!

COMPLETE THE FORM BY SIGNING!

SECURE SIGN AND SEND

PLEASE MAKE SURE TO REVIEW THE ABOVE FOR COMPLETENESS AND ACCURACY BEFORE SUBMITTING. THE INFORMATION YOU ENTER WILL BE SENT ONLY INTO SECURE MEDICAL RECORDS. AFTER YOU SIGN, PROCEED TO STEP 3, THE APPOINTMENT PAGE. YOU MAY REVIEW THE CONSENTS YOU SIGNED AT ANY TIME IN TERMS

Signature*

Tooth Whitening Consent Form