PROCEDURE DESCRIPTION
Teeth whitening (bleaching) is a process of lightening the color of teeth using a chemical agent that breaks down stains. The degree of whitening will vary from patient to patient, depending on the structure of the teeth, the number of applications, and/or the duration of time that the system is used.
POTENTIAL RISKS AND COMPLICATIONS
Tooth Sensitivity: Some patients may experience tooth sensitivity during the treatment. The sensitivity is usually transient and subsides after the completion of the treatment.
Gum Irritation: Whitening can cause temporary irritation of gums or soft tissues in the mouth, particularly if higher concentrations of the whitening agent are used.
Variations in Color Uniformity: Pre-existing dental work such as crowns or veneers will not bleach and therefore may need to be replaced to match the new tooth shade.
Incomplete Whitening: Teeth with multiple colorations, bands, or spots due to tetracycline use or fluorosis may not achieve a uniform color change.
Relapse: After a period (usually 1-3 years), the teeth may darken again. Maintenance treatments can be necessary to retain the color achieved.
Throat Irritation or Nausea: Accidental ingestion of the whitening gel may lead to throat irritation or nausea.
CONSENT AND LIABILITY RELEASE
I have requested and consent to receive a teeth whitening treatment. I understand the procedure and accept the potential risks and complications of the teeth whitening treatment as described above. I understand that the practice of dentistry is not an exact science and that no guarantees can be made or assumed about the results of the procedure.
I acknowledge that I am responsible for following the post-care instructions provided by my dentist and that the success of my treatment depends on my compliance with those instructions.
I agree to assume the risks associated with the teeth whitening treatment, including but not limited to the risks described above and any other risks not discussed during our consultation. I do not hold Lori V Beauty Bar LLC, its beauty business , or any other staff members liable for any complications that may occur during or following the teeth whiteningprocedure.
By signing this form, I am freely giving my consent to allow and authorize Lori V Beauty Bar and/or associated dental staff to perform the teeth whitening treatment.