Teeth Whitening Consent Form
Client Information
Name
First Name
Last Name
Date Of Birth
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Month
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Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Social Media Handle or Type N/A
Example @newsmiletx
How did you hear about New Smile ?
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Client
If a friend or client referred you to New Smile please state the name of the person.
Health and Dental Information
Are you using Dental floss in cleaning your teeth?
*
Yes
No
Have you whitened your teeth before ?
*
Yes
No
If yes, please state when ?
*
Do you have sensitive teeth ?
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Yes
No
Do you have any crowns, bridges, veneers, or fillings?
*
Yes
No
If yes, please state where ? If No please type “N/A”
Are you pregnant?
*
Yes
No
Do you have any allergies?
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If yes, then please specify it on the field above.
Lifestyle:
Do you use any of the following? Please check all that apply:
*
Tea
Coffee
Dark Sodas
Red Wine
Tobacco Products
N/A
Waiver and Consent
Type a question
GENERAL: I acknowledge that I am purchasing a Self Help Teeth Whitening Service that is designed to whiten the colour of my teeth. As a part of the purchase, I am asking for assistance in the use of my teeth whitening service, and I understand that I will be allowed to use a specially designed LED Lamp in order to accelerate the whitening process. Most natural teeth can benefit from a teeth-whitening treatment, I understand that everyone’s teeth are different and that results will vary. 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. Also, 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. Also, I am aware that my teeth will never be whiter than the white colour my genes naturally allow. Potential risks although whitening treatments are generally safe, I understand that some of the potential complications of this treatment include, but are not limited to:
GUM/LIP IRRITATION: Whitening gel that comes in contact with gum tissue or the lips during the treatment may cause inflammation or whitening of these areas. This is due to inadvertent exposure of small areas of those tissues to the whitening gel. The inflammation and/or whitening of gums and lips is transient, and the colour change of the gum tissue should reverse within 30 minutes. I may feel a stinging and tingling sensation on these soft tissues during the treatment if the gel comes in contact with them.
TOOTH SENSITIVITY: Although uncommon, some clients can experience some tooth sensitivity during the first 24 hours after the whitening treatment. People with existing sensitivity, recently cracked teeth, micro-cracks, open cavities, leaking fillings, exposed roots, or other dental conditions that cause sensitivity may find that those conditions increase or prolong tooth sensitivity after the treatment. Please avoid any sort of cold or extremely hot foods (spicy included) within the first 24 hours of the Teeth Whitening Service.
SPOTS OR STREAKS: Some customers may develop white spots or streaks on their teeth due to calcium deposits that naturally occur in teeth. The peroxide gel does NOT cause these spots. The gel just brings the already existing calcium deposits out and makes them visible again. These usually diminish over time.
RELAPSE: After the treatment, it is natural for teeth colour to regress somewhat over time. This is natural and should be very gradual, but it can be accelerated by exposing the teeth to various staining agents, such as coffee, tea, tobacco, red wine, colas, etc. I realize that I should not eat or drink anything except water during 60 minutes after the treatment because the gel opens the pores of my enamel and makes my teeth very vulnerable to staining agents. I understand that the results of the treatment are not intended to be permanent and that secondary, repeat or touch-up treatments may be needed for me to maintain the colour I desire for my teeth.
ELIGIBILITY: I understand that this treatment CANNOT be used by pregnant or lactating women, people under the age of 16, people with gum disease, open cavities, leaking fillings, or other dental conditions, or people with a known allergy to peroxide and/or to aloe vera. I am not currently taking photoreactive drugs or have consulted with my physician about the use of an LED accelerator lamp with these treatments (Chlorthiazide, Hydrochlorothiazide, Chlorthalidone, Naprosyn, Oxaprozin, Nabumetone , Pirozicam, Doxycycline, Ciprfloxacin, Ofloxacin, Psoralens, Democlocyline, Norfloxacin, Sparfloxacin, Sulindac, Tetracycline, St. John’s Wart, Isotretinoin, Tretinoin). People that have had braces removed should wait for cement residue to wear off before getting a teeth whitening treatment and people with a piercing or other metal objects in the oral cavity should remove them before the treatment as they may turn black. If I feel a sharp pain on a particular tooth during the treatment I should stop the treatment and contact my dentist since this could be a sign of an open cavity.
By signing this document, I indicate that I am not ineligible as per the criteria listed above, that I have read and fully understand this entire document including the possible risks, complications and benefits that can result from the treatment, and that I am performing this treatment under my own responsibility and will not hold [ NEW SMILE ] its owners, suppliers or any of its employees liable for any of the above risks that I may experience. I also certify that I have healthy teeth and gums.
Client Signature
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