Client Evaluation - Teeth Whitening

Address

How did you hear about us?
Allergies?
Have you ever had an adverse reaction to:

Hydrogen Peroxide Peppermint Vitamin E Baking Soda
Have you recently had any dental restorations placed (crowns, bridges, fillings, implants or partial dentures)?

Yes No
Are you scheduled for or anticipating any restoration work in the next 6 months?

Yes No
Have you recently had oral surgery?

Yes No
When was your last dental cleaning (approx)?
Have you used whitening products in the past?

Yes No
If yes, did you see any results?

Yes No
Did you have any negative side effects?

Sensitivity Chemical irritation Burnt tissues
Do you have any areas of gum recession, or sensitive gums?

Yes No
Are you pregnant or nursing?

Yes No
Do you suffer from diabetes for epilepsy

Yes No
Before and after pictures are always completed with our treatments. Do we have your permission to post your pictures to social media, the website, and as possible educational purposes? *

Yes No
Is there any other information we should know?
Should be Empty:

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