Clone of Teeth Whitening Pandemic Consent Form

LASER TEETH WHITENING CONSENT

INFORMED CONSENT FORM IN-OFFICE TEETH WHITENING TREATMENT INTRODUCTION

IF YOU ARE UNDER THE AGE OF 18, YOUR PARENT/GUARDIAN MUST SIGN THIS FORM FOR YOU. THEY ALSO NEED TO BE PRESENT DURING THE WHITENING SESSION

This information has been given to me so that I can make an informed decision about having my teeth whitened. I may take as much time as I wish to make my decision about signing this informed consent form. I have the right to ask questions about any procedure before agreeing to undergo the procedure. I would like to have my teeth lightened via the “in-office” technique. *

DESCRIPTION OF THE PROCEDURE

__In-Office Whitening is a procedure designed to lighten the color of my teeth using a whitening gel. This treatment involves using the gel to produce maximum whitening results in the shortest possible time.*

__During the procedure, a whitening gel is used for three 20-minute sessions, with an optional fourth 20-minute session. During the entire treatment, a retractor will be used. *

__Gum/Lip/Cheek Inflammation/Burn – Improper isolation during the whitening procedure may cause or result in (i) inflammation of your gums, lips or cheek margins due to exposure of a small area of those tissues to the whitening gel or (ii) a chemical burn due to whitening gel coming in contact with soft tissue. The inflammation or burn is temporary, and will subside in a few days, but may persist longer and may result in swelling of lip, or white patch on gums. It will subside in a couple of days. To avoid this, we ask that you do not talk during this procedure, to help avoid any complications. If you happen to feel any tingling during the treatment to let your tech know right away.*

__I will be provided protective eyewear for my eyes. Before and after the treatment, the shade of my teeth will be assessed and recorded. Before and after photos will be taken.*

RISKS OF TREATMENT

_I understand that In-Office whitening treatment results may vary or regress due to a variety of circumstances. I understand that almost all-natural teeth can be lightened from In-Office Whitening treatment. I understand that teeth with bonding, veneers, or caps can only lighten to original shade.*

__I understand that teeth with multiple colorations, bands, splotches or spots due to tetracycline use or fluorosis do not whiten as well and may need multiple treatments or may not whiten at all. I understand bruised teeth may not whiten in the same manner as other teeth.*

__I understand that the results of my In-Office Whitening cannot be guaranteed. Not everyone whitens the same.*

___I understand that although my hygienist/technician has been trained in the proper use of the In-Office Whitening system, the treatment is not without risk. I understand that some of the potential complications of this treatment include, but are not limited to: *

___Tooth Sensitivity is rare and is usually mild, but it can be worse in susceptible individuals. Usually, tooth sensitivity or pain following a whitening treatment subsides after a few days. People with existing sensitivity, recession, exposed dentin, exposed root surfaces and large wear facets (severely worn teeth), damaged or missing enamel, cracked teeth, cavities, leaking fillings, or other dental conditions that cause sensitivity or allow penetration of the gel into the tooth may find that those conditions increase or prolong tooth sensitivity or pain after whitening treatment. We recommend ibuprofen or Sensodyne white toothpaste to help with any discomfort that may arise. *

___After the whitening treatment, it is natural for teeth that underwent the whitening treatment to regress somewhat in their shading after treatment. This is natural and should be very gradual but it can be accelerated by exposing the teeth to various staining agents. So, a second season may be needed depending on whitening goal, and maintenance is required every so often to maintain desired shade.*

___I understand that the results of the whitening treatment are not intended to be permanent. That after a period, without proper maintenance they will revert to original shade. I understand that after treatment, I will be required to refrain from consuming any substances that could discolor my teeth for the first 48 hours after treatment. These substances include: coffee, teas, and colas, ALL tobacco products, mustard or ketchup, red wine, soy sauce, berries, berry pie, and red sauces. DO NOT use any charcoal powders, blue mouthwash, or colored toothpaste. Please ask your tech if you have any questions.*

PANDEMIC PRECAUTIONS

__I am not currently sick or experiencing any coughing, fever, or shortness of breath, nor have I been in contact with anyone who is sick.*

__I understand, and I agree to the following safety precautions including but not limited to forehead temperature scans, hand sanitizer, having to wipe down belongings with a Clorox wipe, protective coverings for shoes, etc*

By signing this informed consent I am stating I have had this informed consent (or it has been read to me) and I fully understand it and the possible risks, complications and benefits that can result from the whitening treatment and that I agree to undergo the treatment as described by my teeth whitening tech.

__I understand that after my service has been completed, payment is due. I also understand that there are absolutely NO REFUNDS OF ANY KIND after a completed service.*

__I waive my right to take any form of legal action of any kind, against SWSATL (which includes suing or trying to get any compensation) after a whitening is performed. *

SIGNATURES

By signing this document in the space provided I indicate that I have read and understand the entire document and that I give my permission for the In-Office whitening treatment to be performed on me

FULL NAME

First NameLast Name

DATE

Date

WITNESS NAME

First NameLast Name

DATE

Date

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