Teeth Whitening CONSENT + LIABILITY

I acknowledge that I have been advised that a tooth whitening treatment is a cosmetic service and that its results cannot be guaranteed.

I understand that the degree of whitening achieved varies from person to person and depends on factors such as tooth structure, age, diet, and oral hygiene habits.

I have been informed that there may be risks and side effects associated with teeth whitening, and I have been given the opportunity to ask any questions I may have about the procedure.

I understand that the teeth whitening process will involve the application of a whitening gel to my teeth and the use of a specialized LED light to activate the gel.

I acknowledge that the treatment may cause temporary tooth sensitivity and gum irritation, and that I should inform the technician immediately if I experience any discomfort during the procedure.

I understand that the teeth whitening treatment may not be effective for teeth that are discolored due to certain medications, trauma, or other factors, and that additional treatments may be necessary to achieve the desired level of whitening.

I understand that teeth whitening is not recommended for pregnant or nursing women, individuals under the age of 18, or individuals with certain dental conditions such as gum disease, tooth decay, or exposed roots.

I hereby consent to the teeth whitening procedure and release the technician and the facility from any liability related to the treatment.

I acknowledge that I have read and understand the risks, benefits, and limitations of teeth whitening as described above, and that I have had the opportunity to ask any questions I may have about the procedure.

I certify that I am over the age of 18 and that the information provided on this form is accurate and complete to the best of my knowledge.

Have you had any recent dental work? 

Have you ever experienced tooth sensitivity or gum irritation after a teeth whitening treatment?

Are you currently pregnant or nursing?

Are you taking any medications or supplements that may affect teeth whitening? Ex: antibiotic medication

Have you had any allergic reactions to dental or cosmetic products in the past? please describe:

Are you currently undergoing any medical treatment or taking any medications for a medical condition?

Have you ever had a joint replacement or other surgical procedure that required antibiotics prior to dental treatment? If yes, please describe:

I acknowledge that the information provided on this form is accurate and complete to the best of my knowledge. I understand that the teeth whitening treatment may not be suitable for everyone, and that the technician will determine my eligibility for the procedure based on the information provided on this form and a physical examination.

My goal is to provide quality care in a timely manner. In order to do so, I have to implement an appointment/cancellation policy.

Appointments are in high demand, and your early cancellation will give another person the opportunity to have access to timely care. This policy enables me to better utilize available appointments for my clients.

At the time of booking your appointment you will be asked to pay a $25.00 deposit that will be credited towards your treatment/s.

Time has been specifically reserved for your appointment, procedure, or treatment. If you need to cancel or reschedule your appointment you must call at least 24 hours before your appointment and your deposit will either be refunded or pushed for a future appointment. However, providing less than 24 hours' notice will require you to pay a 50% of your service in cancellation fees.

If you arrive more than 15 minutes late for your appointment it is considered a no-show and you will be charged the cancellation fee.

I have read and fully understand the above Appointment Cancellation Policy and agree to be bound by its terms. I agree to pay the cancellation fee in the event of a missed appointment.

I hereby grant and authorize Maya Garcia of Hot Tottie Beauty the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any pictures, videos, and /or audio taken of me to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social media sites, and other print and digital communications, without payment or any other consideration.

This authorization shall continue indefinitely and extends to all languages, media, formats, and markets now

I waive any rights to royalties or other compensation arising or related to the use of the photograph or recording.

I understand and agree that these materials shall become the property of Hot Tottie Beauty and will not be returned and causes of action which I, my heirs, representatives, executors, administrators, or any I hereby hold harmless and release (Hot Tottie Beauty) as well as other actions persons that represent me may make while acting on my behalf or behalf of my estate.

By signing below, I hereby acknowledge that I have completely read and fully understand the above release agreement.

Congratulations on your new bright smile! To ensure the best results and longevity of your teeth whitening, please follow these aftercare instructions:

Avoid consuming staining beverages and foods such as coffee, tea, red wine, and berries for the first 24 hours after your teeth whitening procedure.

Avoid smoking or using any tobacco products for at least 24 hours after your teeth whitening procedure.

Maintain good oral hygiene by brushing and flossing regularly.

Use a desensitizing toothpaste if you experience any sensitivity after your teeth whitening procedure.

Continue to visit your dentist regularly for routine check-ups and cleanings to maintain the health of your teeth and gums.

If you have any concerns or questions about your teeth whitening, please do not hesitate to contact (361) 389-9299.

Remember, the longevity of your teeth whitening results depends on many factors such as diet, oral hygiene, and lifestyle habits. Following these aftercare instructions will help you maintain a bright and healthy smile for years to come.

Thank you for choosing me for your teeth whitening needs!

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Email: hottietottiecreates@gmail.com