Consent to Teeth Whitening Treatment Consent to Teeth Whitening Treatment Please Read each and Click to check that you fully understand. * If I experience any pain or discomfort during the session, I will immediately inform the provider so that the products and/or technique may be adjusted to my level of comfort. * General - I understand that I am participating in a professional teeth whitening procedure that is designed to lighten the color of my teeth. I understand that I will be allowed to use a specially designed LED Lamp in order to accelerate the whitening process. * Results Guarantee- Although most natural teeth can benefit from a teeth whitening treatment, I understand that everyone's teeth are different and that results will vary. I understand that people with yellowish teeth generally get the best results and that if my teeth have sports due to tetracylcline use (grayish tint) or fluorosis, these will be difficult to whiten. Also, if I have artificial teeth, caps, crowns, veneers, porcelain, composite or other restorative materials, I shouldn't expect dramatic results from this treatment because the peroxide gel will not whiten (or damage) artificial dental work. ***Also, I am aware that my teeth will never be whiter than the white color my genes naturally allow. * GUM/LIP IRRITATION: Whitening gel that comes in contact with gum tissue or the lips during the treatment may cause inflammation or whitening of these areas. This is due to inadvertent exposure of small areas of those tissues to the whitening gel. The inflammation and/or whitening of gums and lips is transient, and the color change of the gum tissue will reverse within 30 minutes. I may feel a stinging and tingling sensation on these soft tissues during the treatment if the gel comes in contact with them. * TOOTH SENSITIVITY: Although uncommon, some customers can experience some tooth sensitivity during the first 24 hours after the whitening treatment. People with existing sensitivity, recently cracked teeth, micro-cracks, open cavities, leaking fillings, exposed roots, or other dental conditions that cause sensitivity may find that those conditions increase or prolong tooth sensitivity after the treatment. * SPOTS OR STREATS: Some customers may develop white spots or streaks on their teeth due to CALCIUM DEPOSITS that naturally occur in teeth. These spots are NOT caused by the peroxide gel. The gel just brings the already existing calcium deposits out and makes them visible again. These usually diminish over time. * RELAPSE: After the treatment, it is natural for teeth color to regress somewhat over time. This is natural and should be very gradual, but it can be accelerated by exposing the teeth to various staining agents, such as coffee, tea, tobacco, red wine, colas, etc. I realize that I should not eat or drink anything except water during 60 minutes after the treatment because the gel opens the pores of my enamel and makes my teeth very vulnerable to staining agents. If I purchase a touch-up pen, I realize that my pores will remain open for as long as I use it so I should refrain from staining agents till I stop using the pen. Only 24 hours after I conclude the touch-up pen treatment can I resume my normal habits. I understand that the results of the treatment are not intended to be permanent and that secondary, repeat or touch-up treatments may be needed for me to maintain the color I desire for my teeth. * ELGIBILITY: I understand that this treatment CANNOT be used by pregnant or lactating women, people under the age of 14, people with gum disease, open cavities, leaking fillings, or other dental conditions, or people with a known allergy to peroxide and/or to aloe vera. People that have had braces removed should wait 6 months for cement residue to wear off before getting a teeth whitening treatment and people with a piercing or other metal objects in the oral cavity should remove them before the treatment as they may turn black. If I feel a sharp pain on a particular tooth, during the treatment I should stop the treatment and contact my dentist since this could be a sign of an open cavity. * I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session. * Acknowledgement: I understand and acknowledge that payments for the above services are non-refundable. By my signature below, I certify that I have read and understand the contents of this Consent Form. * ***I further agree to provide a 24 hour cancellation notice or change of appointment time, or will forfeit a treatment off my package since treatments are by appointment only. There are not refunds on package sessions since they are highly discounted, if decide to stop treatments. Should I decide to add a treatment, that treatment will be considered an additional and separate treatment. * By signing this document, I indicate that I am not ineligible as per the criteria listed above, that I have read and fully understand this entire document including the possible risks, complications and benefits that can result from the treatment, and that I am performing this treatment under my own responsibility. I also certify that I HAVE HEALTHY TEETH AND GUMS. Am I currently pregnant and/or nursing? * No Yes Client Name * First Last Name * Last Email * Phone Client Signature * signature keyboard Clear Submit If you are human, leave this field blank. Δ
