Informed Consent for Teeth Whitening

Teeth Whitening New Client Form
General Information:
Name:*

First NameLast Name
Phone:*
Date of your appointment:

MonthDayYear
Date
Email:
example@example.com
Would you like to be added to our email list for specials and discounts?

YesNo
How did you hear about Smiles By Simone
Dental History:
Have you whitened your teeth before?*

YesNo
If yes, please state when?
Do you have any crowns, bridges, veneers, or fillings?*

YesNo
If yes, please state where?*
Do you have sensitive teeth?*

YesNo
When was your last dental visit?
Medical History:
Do you currently or have you had any of the following? Please check all that apply:

Bleeding GumsTooth DiscolorationDental TraumaSores in MouthUntreated Dental IssuesNone
Are you pregnant?*

YesNo
Are you currently taking any medication? If yes, please explain:
Any known allergies ? If yes, please list:
Lifestyle:
Do you use any of the following? Please check all that apply:*

TeaCoffeeDark SodasRed WineTobacco Products
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.
Name Printed*
signature*

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Date

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Date
Informed Consent for Teeth Whitening:
General:*

I understand that I am participating in a professional teeth whitening procedure that is designed to lighten the color of my teeth.I understand that the teeth whitening procedure uses a specially designed LED lamp in order to accelerate the whitening process.
Results Guarantee:*

I understand that people with yellowish teeth generally get the best results and that if my teeth have spots due to tetracycline use (grayish tint) or fluorosis, these will be difficult to whiten.I understand that although most natural teeth can benefit from a teeth whitening, everyone’s teeth are different and that results will vary.I understand that results vary and that I may need multiple treatments to achieve the results I want.I understand that if I have artificial teeth, caps, crowns, veneers, porcelain, composite or other restorative materials, I shouldn’t expect dramatic results from this treatment because the peroxide gel will not whiten (or damage) artificial dental work.I understand that my teeth will never be whiter than the white color my genes naturally allow.I understand that the results of the whitening treatment are not intended to be permanent and that touch-up appointments every 3-4 months are recommended to maintain the shade I desire for my teeth.
Potential Risks: Although whitening treatments are generally safe. I understand that there can be potential complications of this treatment include, but are not limited to:*

I understand that gum/lip irritation can happen if the whitening gel comes in contact with gum tissue or lips during the treatment and that it may cause inflammation or whitening of these areas. I understant that some tingling or stinging sensation on these soft tissues can happen during the treatment if any gel comes in contact with them. (This is transient and will reverse in about 10-30 min).I understand that while some tooth sensitivity is normal and should only last the first 24 hours after the whitening treatment the following may make teeth more sensitive after treatment: (existing sensitivity, damaged or missing enamel, tooth recession, cracked teeth, exposed dentin, cavities, exposed root surfaces, leaking fillings, severely worn teeth).I understand white spots or streaks may happen on my teeth due to calcium deposits that naturally occur in teeth and that these spots are NOT caused by the peroxide gel. These spots diminish in about 3-4 days.I understand that it is natural for teeth to regress after treatment and that exposing the teeth to various staining agents such as dark-colored liquids (coffee, tea, dark sodas), all tobacco products, mustard or ketchup, red wine, soy sauce, berries, and red sauces can stain my teeth again.
Eligibility:*

I understand that this procedure should NOT be administered on me if I am pregnant, nursing, have not seen a dentist in two years, have unfilled cavities in my teeth, have a temporary crown, or have untreated gum disease.
Name Printed*
Signature*

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Date

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Date
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Teeth Whitening New Client Form

General Information:

Dental History:

Medical History:

Lifestyle:

Informed Consent for Teeth Whitening: