Client Evaluation - Teeth Whitening
by Beautiful Bright Smile
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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?
Submit
Should be Empty:
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