KNK Studios – Teeth Whitening Waiver & Client Consent

KNK Studios – Teeth Whitening Waiver & Client Consent

This waiver covers client information, consent to cosmetic teeth whitening, acknowledgement of risks, studio rules, cancellation/deposit policies, and final authorization.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Have you ever had a reaction to any of the following ingredients: (IF SO THIS PROCEDURE CANNOT BE OPERATED)
Have you had any dental procedures done recently (crowns, bridges, fillings, implants, veneers, partial dentures)? If so- when?
Are you SCHEDULED or planning any restoration work within the next 6 months?
When was your last dental cleaning?
Do you suffer from areas of recession or sensitive gums?
Have you used whitening products in the past?
IF yes- did you see any results? What did you use?
OR: did you have bad side effects like sensitivity, chemical irritation, etc?
Do you have a history of cold sores?
Acknowledgement of Pre/Post-Care & Contraindication Information
I have reviewed CONTRAINDICTIONS above &
I have reviewed and understand all pre-care & post-care
Information & Treatment Expectations

Cosmetic teeth whitening lifts surface staining only and is not a medical dental treatment. Most clients lift 5–14 shades depending on enamel genetics and starting shade. Whitening gel cannot lighten crowns, veneers, bonding, caps, or composite beyond their original color.
Our whitening product is a hybrid mix of 18% hydrogen peroxide and 6% carbamide peroxide. This is a high intensity gel combined with a blue light which activates the gels components. This procedure may or may not require additional whitening in order to achieve your desired whitened shade.
I understand this is a CUSTOM application, there are no trays
The amount of whitening cannot be guaranteed or predicted. Teeth WILL NOT whiten past the original whiteness of your teeth. Yellow or brown teeth with SURFACE stains will white quicker. GREY or BLUISH teeth may need several treatments but may NOT be able to FULLY whiten. Striped or spotted teeth are also difficult to whiten. Fillings, crowns, veneers will whiten to their ORIGINAL COLOR when first placed removing stains.
Pregnant or nursing women are asked to obtain doctor consult before booking a session, clients 12-16 (with adult teeth) require adult consent.
Our gel has adjusted PH (acidity) and conditioners to reduce gum and teeth sensitivity as well as we use vitamin E, desensitizing gels during the session and occasionally gingival barriers for higher HP gels. In the unlikely event sensitivity occurs it may be present for 1-2 days.
If the whitening gel comes into contact with the gums, it MAY cause tingling or blanching. Blanching (white spots) may occur but is not harmful in any way. It will disappear in 1-2 days with normal saliva.
If you have fillings that are breaking down, decay in your teeth, erosion of the teeth, or exposed root surfaces, the gel may come in contact within these areas and may causes sensitivity during / after the treatment. Sensitivity with go away within 1-2 days.
Whitening results vary per person depending on genetics, enamel health, and staining habits, and that no specific shade results are guaranteed. Clients will continue to whiten over the 24 hour period so aftercare is SO important. I have read and reviewed both the pre and post after care above.
Photo / Video Consent

KNK Studios documents with photos of all clients on all services. The below is a consent regarding public / social media
I understand photos will be taken for documentation, BUT
Deposit, Cancellation & Lateness Policies

All services require a non-refundable deposit at booking. Most services require a 50% deposit; some vary based on the service.
- I agree to the non-refundable deposit policy.
Cancellations with less than 24 hours’ notice or no-shows will forfeit the deposit.

-I agree to the cancellation policy.
Arriving more than 10 minutes late may result in rescheduling and loss of deposit.

-I agree to the lateness policy.

-I understand that if I am unwell or am having a cold sore outbreak I would need to reschedule my appointment. If you feel like you may be getting a cold sore coming on, please send me a message in advance, I’m happy to preemptively rebook you.
I have read all above regarding deposits, cancellation and lateness and ...
Studio Rules
No children under 19 allowed.

No pets allowed.

One guest maximum, pre-approved.

New deposit required if a policy is violated.
Final Declaration & Liability Release

By signing below, I confirm the information I provided is truthful. I understand the nature of cosmetic teeth whitening, expected outcomes, aftercare requirements, and risks. I voluntarily agree to proceed and consent to receiving cosmetic teeth whitening at KNK Studios and release KNK Studios from liability when proper protocols are followed.
Signature
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KNK Studios – Teeth Whitening Waiver & Client Consent

Acknowledgement of Pre/Post-Care & Contraindication Information

Information & Treatment Expectations

Photo / Video Consent

Deposit, Cancellation & Lateness Policies

Studio Rules

Final Declaration & Liability Release