20 or 30 Minute LED Teeth Whitening Service Information and Consent EXPECTED RESULTS: People with healthy teeth and gums but who have stains or a yellowish tint seem to get the best results. I understand that if my teeth have spots due to tetracycline use (grayish tint) or fluorosis, these will be difficult to whiten. On some occasions, you may feel a little tingling or perhaps a slight sensitivity for a short time after treatment. You may see temporary bleaching to the gums but this normal and will disappear, usually in less than a day. Although most natural teeth can benefit from a teeth whitening treatment, I understand that everyone's teeth are different and that results will vary. 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. Possible white spots or demineralization may appear on patients who have had braces or who have porous enamel, but this will disappear in 24 hours. 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 theses 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 STREAKS: 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. AFTERCARE: For a minimum of 24 hours after the process, please avoid consuming coffee, tea, dark colored soda, red wine, curry, beetroot and any other food or drink that would stain the teeth. A good rule of thumb is that if it would stain a white shirt, it could stain your teeth. If your teeth are sesitive you can use Sensodyne Toothpaste for immediate relief. Of course, we suggest that you brush and floss as directed by your dentist. ELIGIBILITY: 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 allergyto peroxide and/or to aloe vera. People that have had braces removed should wait 6 months for cement residue towear off before getting a teeth whitening treatment and people with a piercing or other metal objects in the oralcavity 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. By signing this document, I indicate that I am not ineligible as per the criteria listed above, that I have read and fullyunderstand 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 AS DETERMINED BY MY DENTIST OR DENTAL PROFESSIONAL. CONSENT: Revive Massage Chicago LLC recommends that your dentist is consulted prior to using any and all applications. I also agree to hold harmless and fully discharge and release forever and all time the officers, directors, employees, staff members, agents, contractors, successors and assign of Revive Medspa LLC, Revive Massage Chicago LLC, Revive Skin Care & MedSpa LLC, and Revive MSO LLC from any costs, expenses, or other liability whatsoever, including but not limited to attorneys' fees, compensatory, punitive, exemplary, consequential and special damages of any kind whatsoever, resulting from the service I have voluntarily chosen to undergo and any condition or result, known or unknown, that may arise as a result of such procedure or any other treatment I receive. As of December 26, 2024, I am of lawful age (18) and have read and fully understand the contents of this document and represent myself as physically capable of using the service offered by Revive Medspa LLC, Revive Massage Chicago LLC, Revive Skin Care & MedSpa LLC, and Revive MSO LLC. By signing this document, I agree that I have had sufficient time to read this entire document and ask any questions regarding the treatment I have elected to receive. Furthermore, my signature indicates that I have read and understand the information in the consent, and I understand all of the risks and potential complications connected to the procedure I have elected to undergo. I understand that the results of the treatment varies on an individual basis and that specific results are not guaranteed. I understand that while every precaution will be taken to prevent complications and that while complications from this procedure are rare, they can and sometimes do occur I have read the above and certify that I have consulted with my Dentist in the past 30 days and have confirmed that I have healthy teeth and gums. CANCELLATION POLICY: Our Team of Licensed Professionals are only paid when they provide a service and only come to work when they have an appointment, so it is imperative that you provide us with at least 24 hours notice should you need to change or cancel your appointment. It is how they make a living and provide for themselves and families. Your appointment is reserving time on their calendar and it is preventing another client from doing the same. All that we ask is that you extend the courtesy to notify us in a timely manner (24 hours) should something change and you are unable to keep your appointment. If you cancel the same day or fail to show up for your appointment, your credit card will be charged for the entire amount of the service and you will be required to pre-pay for any future appointments, including past missed appointments. If you have an outstanding gift certificate, package credit or reward points, it will be redeemed for your missed appointment. By signing this document, you agree to and understand our cancellation policy. Product Sales/Gift Cards/Gift Certificates/Packages: All product sales are final and are non-refundable. In addition, Gift Certificates/Gift Cards and Packages for all services are non-refundable regardless if they were purchased online or in-store. By signing below, I fully understand the elected treatment, expected results, cancellation policy and am able to receive the treatmentas outlined above.
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