Teeth Whitening Consent Form
Studio Magnolia
Client Information
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health and Dental Information
Have you had a Teeth Whitening treatment before?
Please Select
Yes
No
Do you smoke?
Please Select
Yes
No
Do you have dental restorations?
Please Select
Yes
No
Please list:
Do you have any known tooth decay or broken teeth?
Please Select
Yes
No
Do you have any allergies?
If yes, then please specify it on the field above.
Are you currently taking any medications?
If yes, then please specify it on the field above.
Do you have any medical conditions that we should be aware of? (Communicable disease, cardiovascular problems, diabetes, etc.)
If yes, then please specify it on the field above.
Waiver and Consent
Type a question
I authorize Studio Magnolia to perform this procedure to me.
I allow Studio Magnolia to use any photos or videos taken for social media, website, or promotional reasons.
I understand the risk and complications if I do not follow the instructions given to me after the procedure which involves post-treatment and follow-ups.
I release Studio Magnolia for any responsibility in case of an accident, illness, or injury.
I acknowledge that all information I provided in this form is true and accurate.
Signature of the Patient
Date Signed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: