TEETH WHITENING TREATMENT CONSENT FORM

TEETH WHITENING TREATMENT CONSENT FORM
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
This information has been given to me so that I can make an informed decision about having my teeth whitened. I will take as much time as I wish to make my decision about signing this consent form. I will ask questions about the procedure before undergoing.

Description of the procedure

Teeth whitening is a procedure designed to lighten the color your teeth using a peroxide or non-peroxide gel. The whitening treatment uses the gel to maximize the whitening results in the shortest time possible. During the procedure the whitening gel will be applied to your teeth for 2+ 20-minute sessions. Your lips and gums will be protected, and you will be provided protective eyewear.
Risks of treatment (initial each line)
I understand that teeth whitening treatments vary or regress due to a variety of*
I understand that after the treatment, I will be required to refrain from consuming any that could discolor my teeth for the first 48 hours after treatment. These substances*
I understand that after the 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, colas, all tobacco products, mustard, ketchup, red wine, soy sauce, berries, berry pie, and any red sauces.*
I understand that results cannot be guaranteed*
I understand the results of my treatment are not intended to be permanent*
I understand that teeth with multiple colorations, bands, or spots may need multiple or may not whiten at all.*
I understand that teeth with multiple colorations, bands, or spots may need multiple treatments or may not whiten at all.*
I understand that teeth with many fillings, cavities, chips or cracks may not lighten.*
I understand some of the potential complications of this treatment include but aren't limited to: Some tooth sensitivity is normal and is usually mild if it happens but can be worse in susceptible induvial. People with existing sensitivity, recession, exposed dentin, severely worn out teeth, damaged or missing enamel, cracked teeth, cavities, leaking fillings, or other dental conditions that cause sensitivity may increase or prolong sensitivity or pain after treatment.*
By signing this consent form, I am stating that I have read this document and I fully understand it. I understand the possible risks, complications and benefits that can result from the whitening treatment and I agree to undergo the treatment.
Name:*
Date:*

MonthDayYear
Date
Signature:*

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Parent Guardian Signature:

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TEETH WHITENING CLIENT INFORMATION
Name:*
Date:*

MonthDayYear
Date
Phone:*
Allergies:*
Are you pregnant or nursing (if yes we suggest vegan whitening)?*

YesNo
Do you have Diabetes?*

YesNo
Do you have Epilepsy (if so, you are not eligible for the procedure)?*

YesNo
Crowns, bridges, fillings, implants, partial dentures or any other oral surgery scheduled in the next 6 months*

YesNo
Guarantees (please initial):
I understand that there are no guarantees, results may vary.*
I understand that additional whitening sessions may be required to obtain the ultimate result.*
I have read and initialed this consent form and understand the risks and benefits*
Consent (please initial):
I have had the opportunity to ask questions regarding this procedure.*
I consent to treatment and I assume all responsibility for the risks described above.*
Signature:*

Clear
Parent Guardian Signature:*

Clear

Staff Space