Teeth Whitening New Client Form

Teeth Whitening New Client Form
General Information:
Full Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Date of your Appointment:

MonthDayYear
Date
Email:
example@example.com
How did you hear about MarsBeautyLab?
Please Specify
Dental History:
Have you whitened your teeth before?
If yes, please state when?
Do you have any crowns, bridges, veneers, or fillings?
If yes, please state where?
Do you have sensitive teeth?
When was your last dental visit?
Medical History:
Do you currently or have you had any of the following? Please check all that apply:
Are you pregnant?
Are you currently taking any medication? If yes, please explain:
Any known allergies ? If yes, please list:
Lifestyle:
Do you use any of the following? Please check all that apply:
Informed Consent for Teeth Whitening:
General
Potential Risks: Although whitening treatments are generally safe. I understand that there can be potential complications of this treatment include, but are not limited to:
Results Guarantee:
Eligibility:
Oversight and Documentation
- I give my consent for before-and-after photos of my teeth to be taken and submitted for quality assurance purposes.
- These images are used solely for professional documentation and will not be shared publicly without written consent.
Photo Request

Please provide us with a clear before photo of your teeth prior to your appointment. This helps us track your progess and ensure proper documentation.
File Upload

Cancelof
Consent and Acknowledgment

By signing below, I confirm the following:
- I have completed this form truthfully and to the best of my knowledge.
- I agree to notify the technician of any changes to the information provided.
- I confirm that I do not have any condition(s) that would make the requested treatment inappropriate.
- I will promptly inform the technician of any discomfort experienced during the procedure so adjustments can be made as needed.
- I waive all liability against the technician for any injury or damages resulting from any misrepresentation or omission regarding my health.
Disclaimer: This cosmetic teeth whitening service is not intended to diagnose, treat, or cure any dental conditions and is not a substitute for professional dental care. Clients are responsible for maintaining regular dental checkups and must disclose any changes in their oral health prior to each appointment.
Name Printed
Date

MonthDayYear
Date
Signature
Should be Empty:

Teeth Whitening New Client Form

Dental History:

Medical History:

Lifestyle:

Informed Consent for Teeth Whitening: