Tooth Whitening Consent Form
Patient Information
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health and Dental Information
Toothpaste Brand
Are you using Dental floss in cleaning your teeth?
Please Select
Yes
No
Are you using braces?
Please Select
Yes
No
Do you have tooth filling?
Please Select
Yes
No
Do you have any known tooth decay or broken teeth?
Please Select
Yes
No
Do you have any allergies?
If yes, then please specify it on the field above.
Are you currently taking any medications?
If yes, then please specify it on the field above.
Do you have any medical conditions that we should be aware of? (Communicable disease, cardiovascular problems, diabetes, etc.)
If yes, then please specify it on the field above.
Waiver and Consent
I authorize Bodied By You Inc to perform this procedure to me and acknowledge that teeth will not whiten past my genetic whiteness. Note: Gray, bluish, striped or spotted teeth are more difficult to whiten. Same goes for fillings, crowns and veneers.
I am aware that Bodied By You Inc uses Hybrid whitening gel and a LED red/blue light, which activates the gel's components. This procedure may or may not require additional whitening in order to achieve your desired lightening shade.
I acknowledge that Bodied By You Inc whitening gels has adjusted Ph (acidity) and conditioners to reduce teeth and gum sensitivity; all teeth react differently. In the unlikelihood sensitivity occurs, it may be present for 1-2 days.
I understand the risk and complications if I do not follow the instructions given to me after the procedure which involves post-treatment and follow-ups.
I release Bodied By You Inc for any responsibility in case of an accident, illness, or injury.
I acknowledge that all information I provided in this form is true and accurate.
Signature of the Patient
Date Signed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: