Teeth Whitening Consent Form

  • Client Intake Form- Teeth Whitening

    This Form is completely confidential. Completion of this form assists the technician in providing the best treatment for you.

  • Personal Information

  • Format: (000) 000-0000.

  • Dental Information

  • Medical Information

  • If yes, please explain?

  • If yes, please explain?

  • TEETH WHITENING EXPECTATIONS

    Davinci  teeth whitening safely removes stains caused by foods, beverages, tobacco, medicine, and aging. For the ultimate whitening effect on your teeth, you have the option to perform up to 3 whitening sessions at this time

    • When whitening you may feel a slight tingling
    • Davinci products will not damage existing dental work
    • Davinci products will remove stains from existing dental work but will not whiten them beyond their original color
    • White spots may appear more prevalent directly after whitening, but the contrast will lesson within 24 hours
    • Everyones teeth respond differently and have their own natural "stop" point for whitening results
    • Teeth may feel temporary sensitivity; sensitivity is typically minor and gone within 24 hours. You may choose to purchase a desensitizing treatment with your whitening.
    • You may expirience temporary gum irritation, which is more prevalent in clients that have brush abrasion from brushing teeth 4 hour prior to whitening

  • Davinci Product

    Davinci product offers enamel strengthening qualities. It is organic plant and mineral based containing NO animal by products. Active ingredient is a food grade Hydrogen Peroxide.

    Rcommendations

    To maintain healthy teeth and gums. It is recommended that you visit your dentist on a regular basis. If you have allergies or reactions to peroxide or glycerin, teeth whitening is not recommended. If you have diabetes, heart conditions, pregnant, and/or currently breastfeeding you may want to consult  with your doctor prior to using whitening products. Ask your representative for a list of ingredients if you have concerns. Any existing mouth sores may feel temporary irratation during and/or after whitening.

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  • Customer Signature

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  • Parent/Guardian Signature

    If you are under the age of 18, parent consent is required

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  • MEDIA RELEASE FORM

    Photo/Video consent and liabilty

  • I give permission for The Glow Biz to take photographic or video recordings that may then be used for social meida, website, promotional amd/or educational use

    I understand that my image may be edited,copied,exhibited,published, or distributed and waive the right to inspect or approve the finished product wherein my likeliness appears. Additionally, I waive the right to royalties or other compensation arising or related to the use of my image or recording.

    By signing this form I verify that I havecompletely read and fully understand the above release and agree to be bound therby. I herby release any and all  claims against any person or organization utilizing this materialfor business or promotional purposes.

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  • Customer Signature

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  • Parent/Guardian Signature

    If you are under the age of 18, parent consent is required

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