New Client Teeth Whitening Form

  • New Client Teeth Whitening Form

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  • Format: (000) 000-0000.
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  • Would you like to added to our email list for specials and discounts?

  • Dental History:

  • Have you ever had your teeth whitened?*
  • Do you have any crowns, bridges, veneers, or fillings?*
  • Do you have sensitive teeth?*

  • Medical History

  • Do you currently or have you had any of the following? Please check all that apply:
  • Are you pregnant*

  • 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.

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  • Informed Consent for teeth Whitening

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  • Should be Empty: