Please fill out form and submit prior to your appointment.

TEETH WHITENING FORM

Teeth whitening is designed to lighten the color of your teeth. Up to 14 shades lighter is attainable, but results cannot be guaranteed. Please keep in mind each person has different teeth and not every client will have the same results. Treatments can be done every 4-6 weeks. When done properly, this service will not harm your teeth or gums.

However, like any other treatment, there are risks and limitations associated with this service. They are seldom serious enough to discourage you from having your teeth whitened, but the following information is provided to be considered. Gum irritation can occur if the solutions leak onto the gum area under the protective coat we place on the area. Any burning sensations should resolve themselves.

While majority of clients are candidates for teeth whitening, the following cases are not eligible for this service:

PREGNANT OR BREASTFEEDING WOMEN
People with dark yellow, dark brown/black, dark gray or blue-ish/gray teeth
People with root canals, gingivitis, plaque buildup, or dead teeth are not eligible for this service
Anyone needing dental work is not a good candidate for this service

Please consider and consent to receiving the following information:

Multi-colored teeth will whiten differently
People with minimal discoloration will not see as drastic results as someone with more prominent staining
It is advised to have seen a dentist within 6 months of this service

Your responsibilities to maintain the best results after your service:

Avoid COLORED, ACIDIC, AND HOT/COLD foods and beverages for the first 48 hours after your session. During this 48 hours window, your teeth are most susceptible to acquiring stains.

Whitening treatment weakens enamel in order to penetrate the solution and dissolve the stain, eating or drinking anything of dark color could actually result in more stains than before the session.

EXAMPLES: COFFEE, WINE, TEA, CHOCOLATE, BEETS, LEMONS/LIMES, FRUIT, ICE-CREAM, SOUP ETC.

AVOID TOBACCO USE

If you do need to use tobacco, please use an e-cigarette to avoid staining.

FOLLOW GOOD DENTAL HYGIENE

Brush teeth immediately after eating foods that could stain your teeth. Use a sensitive toothpaste if needed or brushing often. Brush, floss, and clear mouthwash often!

Take a pain reliever if there is any sensitivity to the tooth or gum area.

I HAVE READ THE INFORMATION PROVIDED AND UNDERSTAND THE TEETH WHITENING PROCEDURE. THE SERVICE PROVIDER, DENISE ANDRADE, HAS EXPLAINED THIS PROCEDURE TO ME AND HAS ANSWERED ALL MY QUESTIONS.

I CONSENT TO TREATMENT

I CONFIRM THAT I AM NOT PREGNANT OR BREASTFEEDING

I CONFIRM THST I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION PROVIDED TO ME

I CONFIRM I HAVE REVIEWED THE INFORMATION PROVIDED AND FEEL KNOWLEDGEABLE ABOUT THE SERVICE

I CONFIRM I HAVE RECEIVED AFTERCARE

I CONSENT TO HAVE THIS SERVICE PROVIDER APPLY PRODUCTS AND PERFORM THIS SERVICE ON ME AS THE CLIENT

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INFORMED CONSENT FORM FOR TEETH WHITENING TREATMENT

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.

In-Office Whitening is a procedure designed to lighten the color of my teeth using a hydrogen peroxide gel. The In-Office Whitening treatment involves using the gel to produce maximum whitening results in the shortest possible time.

During the procedure the whitening gel will be applied to my teeth for two or three 20-minute sessions, with an optional fourth 20-minute session. During the entire treatment, a plastic retractor will be placed in my mouth to help keep it open and the soft tissues of my mouth (i.e. my lips, gums, cheeks and tongue) will be covered to ensure they are not exposed to the gel.

Lip balm may also be applied as needed and I will be provided protective eyewear for my eyes. After the treatment is completed, the retractor and all gel and tissue coverings will be removed from my mouth. Before and after the treatment, the shade of my upper-front teeth will be assessed and recorded.

__I understand that this 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 whitening treatments are not intended to lighten artificial teeth, caps, crowns, veneers or porcelain, composite or other

restorative materials and that people with stained teeth.

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 that teeth with many fillings, cavities, chips or cracks may not lighten and are usually best treated with other non-bleaching alternatives.

I understand that the results of my teeth whitening cannot be guaranteed.

I understand that although my service provider has been trained in the proper use of the teeth 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 normal 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, but it may persist for longer periods of time in susceptible individuals.

People with existing sensitivity, recession, exposed dentin, exposed root surface and large wear facets (severely work 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.

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.

I understand that the results of the whitening treatment is not intended to be permanent and secondary, repeat or take-home treatments may be needed further to maintain the tooth shade I desire for my teeth. 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, berr

Since it is impossible to state every complication that may occur as a result of whitening treatments, the list of complications in this form is incomplete. The basic procedures of whitening treatments and the advantages and disadvantages; risks and known possible complications of alternative treatments have been explained to me by my dentist/hygienist and my dentist/hygienist has answered all my questions to my satisfaction. In 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 dentist and/or their staff.

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.

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Witness Signature

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