Teeth Whitening Consent Form

Teeth Whitening Consent Form

You have a right to be informed about your treatment. This disclosure is not mean to scare or alarm you. It is simply an effort to make you better informed so you may give or withhold your consent for treatment. By signing you are agreeing that you understand and have decided to give your consent to this treatment.
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Have you had any dental work done in the past 6 months?
I understand cosmetic teeth whitening is a non-invasive procedure, no dental equipment is used on the client. All products are FDA approved and made here in the United States. 100% legal to be used outside of a dental office. I understand that I am not being treated by a dentist, my technician has no dental qualifications or license and that my teeth are not being examined for health. cavities, etc. * My technician is only certified**
Initials
I Understand Teeth whitening is designed to lighten the color of your teeth. Significant whitening can be achieved in the vast majority of cases, but the RESULTS CANNOT BE GUARANTEED as everyone’s enamel is different. Everyone’s teeth also have a natural stopping point when it comes to whitening. When done properly, the whitening will not harm your teeth or gums. However like any other treatment it has some inherent risks and limitations. These are seldom serious enough to discourage you from having your teeth whitened, but should be considered when deciding to have the treatment. *
Initials
I understand if I have tooth decay, exposed roots, gum disease, braces, have had a recent oral surgery, are pregnant or other dental problems, to consult my dentist first. This product is NOT recommended if allergic to carbamide peroxide, hydrogen peroxide glycerin or peanuts. Teeth whitening is intended for natural teeth only. This product can be used with but will NOT whiten caps ,crowns, veneers, fillings & dentures or any other type of dental work. *
Intials
I understand the maintenance to get the best results is 2-3 weeks after my first appointment then every 2-3 months to get rid of any new stains & maintain your new smile 🦷*
Intials
I consent to "before and after" photographs/videos for the purpose of documentation, potential advertising and promotional purposes.*
Intials
I understand Dee Only Beauty does not offer refunds. *
Intials
Are you 18 & over ?
Have you had teeth whitening before ?
Are you allergic to any of the following?
Level of sensitivity to hot & cold water
Do you smoke ?
Do you drink any of the following ?
Are you pregnant or think you might be ?
I First Name* Last Name*
*
authorize Dee Only Beauty to perform this procedure on me. I RELEASE DEE ONLY BEAUTY FROM ANY RESPONSIBILITY IN CASE OF AN ACCIDENT, ILLNESS, OR INJURY.I ACKNOWLEDGE THAT ALL INFORMATION I PROVIDED IN THIS FORM IS TRUE AND ACCURATE. I ALSO UNDERSTAND THAT RESULTS ARE NOT GUARANTEED AS EVERYONES ENAMEL IS DIFFERENT. I WILL NOT HOLD DEE ONLY BEAUTY AT FAULT OR LIABLE IF I DO NOT GET THE RESULTS I WANT OR IF MY TEETH DO NOT WHITEN.
I understand and accept the following statements

I am over 18 years of age and consent to the agreement and to treatment or agree that my parents) or guardian gave me consent to this service.This agreement will remain in effect for this procedure and all future procedures conducted by my technician.I read English and understand that this consent agreement is legal and binding. I have read and fully understand all information in this agreement. I release my technician from all liability associated with this procedure, which is performed with the utmost attention to safety and proper application using tools and products that the technician has been professionally trained to use. I understand the aftercare instructions and will do my part to maintain aftercare.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Signature
Should be Empty: