New Client Teeth Whitening Form

Medical History
Do you currently or have you had any of the following? Please check all that apply:

Bleeding gumsTooth DiscolorationDental TramaSores in your mouthUntreated Dental IssuesNone
Are you pregnant*

YesNo
Are you currently taking any medications? If yes please list:
Any know allergies? If yes pleas list:

Lifestyle:
Do you use any of the following? Please check all that apply:*

TeaCoffeeDark SodasRed WineSmoking of any kind
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.
Signature*

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Informed Consent for teeth Whitening
General:*
Results Guarantee: *
Potential Risks: Although whitening treatments are generally safe. I understand that there can be potential complications of this treatment included, but not limited to:*
Eligibility:*
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Dental History: