Mobile Teeth Whitening Consent Form
Client Information
Name
First Name
Last Name
What is address where we will be treating you at? Put N/A if not applicable to your treatment.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Can we get a good email?
example@example.com
What's a good number we can reach you at? Via Text/Call
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Area Code
Phone Number
What is your DOB?
-
Month
-
Day
Year
Date
Health and Dental Information
Have you ever had your teeth professionally whitened?
Please Select
Yes
No
Do you currently have tooth sensitivity? Sensitivity to cold, hot or sugar, or crunchy foods.
Please Select
Yes
No
Do you currently have a diagnosed cavity, crown, root canal, extraction, periodontal disease or gingivitis?
Please Select
Yes
No
When was your most recent dental cleaning & exam?
Waiver and Consent
I have been given this information in order that I may be able to make a informed decision about undergoing a teeth whitening procedure. I am able to take as much time as I need to come to a decision whether or not to sign this informed consent form, I am free to ask why any questions about procedure before I consent to undergoing any procedure.
I understand that I will undergo up to four 20-minute teeth whitening treatments to achieve desired results. The teeth whitening treatment is designed to lighten the color of my teeth and safely whiten stain caused by foods, beverages, tobacco and medications. Amazing Teeth Whitening uses a combination of a hydrogen peroxide gel and a FDA approved LED accelerator.
I understand that during the whitening treatment you may feel a slight tingling. White spots on your teeth may appear more prevalent directly after whitening, but the contrast will lessen within 24 hours. Your teeth may feel temporarily sensitive; sensitivity is typically minor and gone within 24 hours. You may choose to take an Advil to help with relief of sensitivity. You may experience temporary gum irritation, which is more prevalent in clients that have brush abrasion from brushing teeth within 4-6 hours prior to whitening.
I understand that significant whitening can be achieved in the vast majority of cases, but that results cannot be guaranteed. Everyone's teeth respond differently and have their own natural stopping point for whitening results.
Dark yellow and yellow-brown teeth tend to have better results than grey or bluish-gray teeth. I understand that multi-colored teeth, especially if stained due to tetracycline, do not whiten very well.
I understand that I am not being treated by a dentist, my technician is a dental assistant and is not qualifications to exam health, cavities, etc. I am aware that I should be examined by a dentist prior to treatment. I have healthy teeth and gums. Our products will not damage existing dental work but will not whiten them beyond their original color. If I am pregnant or nursing, I have consulted with my OBGYN and have been given the approval to proceed with whitening.
I release AMAZING TEETH WHITENING, from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age, and I am a competent adult parent or legal guardian of the minor listed below. The consent form is freely upon my spouse, relatives, legal representatives, heirs, administrators, successors, and assigns.
I acknowledge that all information I provided in this form is true and accurate. We ask that you please reschedule or cancel at least 24 hours before the beginning of your appointment or you may be charged a cancellation fee of $50.00.
I understand possible side effects can include but are not limited to an allergic reaction to the gel solution, dry/chapped lips, tooth sensitivity, and irritation of the soft tissues (particularly the gums). In some cases, direct exposure to UV lightening or LED lighting can trigger a cold sore outbreak, typically if you are already prone to cold sores.
Signature of the client
Date Signed
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Month
-
Day
Year
Date
Submit
Submit
Should be Empty: