Teeth Whitening Client Intake Form

Teeth Whitening Client Intake Form
Name

First NameLast Name
Phone
Format: (000) 000-0000.
Email
example@example.com
Date of your appointment

MonthDayYear
Date
How did you hear about us?
Have you done teeth whitening before?
Do you have any crowns, bridges, veneers, or fillings?
If yes, please state when?
Do you have sensitive teeth?
When was your last dental visit?
Do your currently or have you had any of the following? Please check all that apply?

Other
Are you or could you be pregnant?
Are you currently taking any medications? If yes, please explain:
Do you have any other allergies? If yes, please list:
Lifestyle:
Do you use any of the following? Please check all that apply:

Other
By signing below, I agree to the following: I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience to allow them to adjust accordingly. I agree to waive all liability toward my technician for any injury or damages incurred due to any misrepresentation of my health.
Name Printed: If you are a minor - parent or legal guardian must print and sign.
Signature
Date

MonthDayYear
Date
Informed Consent for Teeth Whitening
General
Potential Risks
Results Guaranteed
Eligibility
Consent for Use of Media: I give consent for my pictures or videos to be used as before and after examples.
Name Printed: If you are a minor - parent or legal guardian must print and sign.
Signature
Date

MonthDayYear
Date
Should be Empty:

Teeth Whitening Client Intake Form

Lifestyle:

Informed Consent for Teeth Whitening