Professional Teeth Whitening Consent Form
By MinaYourToothPlug
Client Information
Name
First Name
Last Name
Age
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Do you have any allergies?
If yes, then please specify it on the field above.
Waiver and Consent
Type a question
I agree that I am over the age of 18, am NOT under the influence of alcohol or drugs, am NOT pregnant or nursing, and desire to receive the teeth whitening procedure. The general nature of the teeth whitening process has been explained to me
I have been informed of the nature, risks, and possible complications and consequences of teeth whitening. I understand the teeth whitening procedure may have known or unknown complications including but not limited to tooth sensitivity, tingling, minor discomfort, and toothache.
I understand that results may vary per client.
I understand that the teeth whitening procedure is not intended to lighten artificialteeth, composite, crowns, veneers, caps, porcelain, or other restorative materials.
I understand that if I have multiple fillings, cavities, chips, or cracks in my teeth that theteeth whitening procedure is not best suited for me and I should seek an alternative non-bleaching option.
I understand that I may end up with multiple colorations or splotches due to various contributing factors.
I am not pregnant or lactating.
I understand that this procedure is not permanent, and exposing teeth to variousstaining agents will result in changes in shade post-bleaching.
I elect to receive this procedure from "Mina Your Tooth Plug" of my own free will and understanding and accept all of the above information.
I understand this agreement is binding and that I have read and fully understand all information listed above. I represent that I am over the age of 18 or if under the age of 18, I have a parent and/or guardian signature below and that he/she consents to this procedure under these terms. I have completed this form to the best of my ability and knowledge and agree to inquire about questions i may have before "Mina Your Tooth Plug" begins performing the procedure. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform my esthetician of any discomfort I may experience during the requested treatment to allow them to adjust accordingly. I agree to waive all labilities toward my esthetician and "Mina Your Tooth Plug" for any injury or damages incurred due to any misrepresentation of my health history.
Signature of the Patient
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
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