INFORMED CONSENT FOR TEETH WHITENING DESCRIPTION OF THE PROCEDURE In-office tooth whitening is a procedure designed to lighten the color of my teeth using a combination of a hydrogen peroxide gel and a specially designed ultraviolet lamp. treatment involves using the gel and lamp in conjunction with each other to produce maximum whitening results in the shortest possible time. During the procedure, the 32-38% Carbamide Peroxide whitening gel will be applied to a plastic sterilized dental retractor, I will insert it into my mouth and my teeth will be exposed to the light from the UV lamp for one 20-minute session. During the entire treatment, the plastic retractor I 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 either the gel or light. Lip balm (SPF rating: 30+) may also be applied as needed and I will be provided an ultraviolet light filter for my eyes. After the treatment is completed, the retractor and all gel and tissue coverings will be removed from my mouth. A remineralization gel with sodium fluoride will be offered to me to help reduce any sensitivity and remineralize my teeth. Before and After the treatment, the shade of my upper-front teeth will be assessed and recorded. RISKS OF CONSENT FOR TREATMENT I also understand that teeth whitening treatment results may vary or regress due to a variety of circumstances. I understand that almost all natural teeth can benefit from teeth whitening treatments and significant whitening can be achieved in most cases. I understand that teeth whitening treatments are not intended to lighten artificial teeth, caps, crowns, veneers or porcelain, composite or other restorative materials and that people with darkly stained yellow or yellow-brown teeth frequently achieve better results than people with gray or bluish-gray teeth. I understand that teeth with multiple colorations, bands, splotches or spots due to tetracycline use or fluorosis do not whiten as well, may need multiple treatments or and may not whiten at all. I understand that teeth with many fillings, cavities may not lighten and are usually best treated with other non-bleaching alternatives. I understand that provisionals or temporaries made from acrylics may become discolored after exposure to UV teeth whitening treatments. I understand that UV teeth whitening treatment is not recommended for pregnant or lactating women, light sensitive individuals, patients receiving PUVA (Psoralen + UVA radiation) or other photochemotherapeutic drugs or treatment, as well as patients with melanoma, diabetes or heart conditions. I understand that the UV teeth whitening lamp emits ultraviolet radiation (UVA) and that patients taking any drugs that increase photosensitivity should consult with their physician before undergoing treatment. I understand that the results of my treatment cannot be guaranteed. I understand that in-office whitening treatments are considered generally safe by most dental professionals. I understand that a dentist nor a doctor is performing my teeth whitening treatment and that 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/Pain – During the first 24 hours. Treatment, some patients can experience some tooth sensitivity or pain. This is normal and is usually mild, but it can be worse in susceptible individuals. Normally, tooth sensitivity or pain following a treatment subsides within 24 hours, but in rare cases can persist for longer periods of time in susceptible individuals. People with existing sensitivity, recession, exposed dentin, exposed root surfaces, recently cracked teeth, abfractions (micro-cracks), open 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 teeth whitening treatment. Gum/Lip/Cheek Inflammation – Whitening may cause inflammation of your gums, lips or cheek margins. This is due to inadvertent exposure of a small area of those tissues to the whitening gel or the ultraviolet light. The inflammation is usually temporary which will subside in a few days but may persist longer and may result in significant pain or discomfort, depending on the degree to which the soft tissues were exposed to the gel or ultraviolet light. Cavities or Leaking Fillings – Most dental whitening is indicated for the outside of the teeth, except for patients who have already undergone a root canal procedure. If any open cavities or fillings that are leaking and allowing gel to penetrate the tooth are present, significant pain could result. I understand that if my teeth have these conditions, I should have my cavities filled or my fillings redone before undergoing teeth whitening treatment. Cervical Abrasion/Erosion – These are conditions which affect the roots of the teeth when the gums recede and they are characterized by grooves, notches and/or depressions, that appear darker than the rest of the teeth, where the teeth meet the gums. These areas appear darker because they lack the enamel that covers the rest of the teeth. Even if these areas are not currently sensitive, they can allow the whitening gel to penetrate the teeth, causing sensitivity. I understand that if cervical abrasion/erosion exists on my teeth, these areas will be covered with dental dam prior to my teeth treatment. Root Resorption – This is a condition where the root of the tooth starts to dissolve either from the inside or outside. Although the cause of this is still uncertain, I understand that there is evidence that indicates the incidence of root resorption is higher in patients who have undergone root canals followed by whitening procedures. Relapse – After the UV teeth whitening treatment, it is natural for the teeth that underwent the 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. I understand that the results of the treatment are not intended to be permanent and secondary, repeat or take-home treatments may be needed for me
to maintain the tooth shade I desire for my teeth.
The safety, efficacy, potential complications and risks of teeth whitening treatment can be explained to me by my own dentist and I understand that LaserLounge staff members are NOT dentists. I agree to consult my own dentist if I have any further concerns or questions. Since it is impossible to state every complication that may occur as a result of teeth whitening treatment, the list of complications in this form is incomplete. In signing this informed consent I am stating I have read 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 teeth whitening treatment and that I agree to undergo the treatment. Consent 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 teeth whitening treatments to be performed on me. December 22, 2024 CALIFORNIA MEDICAL SERVICES CONTRACT All Medical treatments are performed by Jonathan Serebrin MD, Inc. Medical Group, at LaserLounge A signed copy of this document is to be emailed/given to the client upon request. Original is to be filed in Client’s medical records. Arbitration Agreement California CD0501Y8v2 ARTICLE I: ARBITRATION Article 1.1: Agreement To Arbitrate: It is understood that any dispute as to medical malpractice by Client, including any party that would have standing to assert a claim on behalf of or in connection with services provided to Client, that is as to whether medical services rendered under this contract were unnecessary, unauthorized or lacking informed consent or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. For purposes of this agreement, “Dispute” means any claim or controversy of whatever kind or nature including (without limitation) any claim or controversy regarding the formation, validity, interpretation and/or enforceability of this agreement to arbitrate and any claim or controversy by the Client asserting loss of consortium, wrongful death, emotional distress or punitive damages. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Article 1.2: Procedure For Initiating Arbitration: Either party to this agreement may initiate Arbitration by submitting a Demand for Arbitration in writing to the other. The Demand shall contain a plain and simple statement of the nature of the Dispute and the remedy demanded. There shall be one Arbitrator who shall be a retired Judge of a court of record. The Arbitrator shall be selected by agreement of the parties on or before 30-calendar days of the date that the Demand for arbitration is deposited for delivery with a common carrier (as determined by a postmark or other equivalent writing imprinted by the common carrier). If the parties have not agreed to a selection of the Arbitrator, than either party may petition the appropriate Superior Court to appoint the Arbitrator and, consistent with CCP § 1281.6, the Superior Court shall appoint the Arbitrator, who shall have the qualifications stated in this paragraph. Article 1.3: Law Governing Arbitration; Arbitrator’s Award And Enforcement. Without reference to its choice of law rules, the Arbitrator shall apply the substantive law of California. The Arbitrator shall render his or her award in writing and the award shall separately state the Arbitrator’s findings of fact and conclusions of law. The Arbitrator’s award shall be binding on the parties to the arbitration and judgment on the award may be entered by a court of competent jurisdiction in California. Judicial proceedings to confirm, amend, or vacate the arbitration award shall also take place in California. To the extent permitted by law, venue for such proceedings shall be in the county (or the federal judicial district) where the services were rendered. Unless the Arbitrator shall determine otherwise, the Arbitration shall take place in the county where the services were rendered. The Arbitrator shall have the authority to hear any claim and award any remedy that could otherwise be heard or rendered by the Superior Court of California or a federal district court in California. Discovery shall proceed in accordance with California Code of Civil Procedure, §§ 1283.1, 1282.05, and, in addition, any party, may, of right, bring a motion for summary judgment or adjudication in accordance with CCP § 437c. The parties to this agreement agree to arbitrate in one proceeding all claims arising out of the same or a related incident, transaction or occurrence. Article 1.4: Small Claims Court: Notwithstanding the foregoing any party to this agreement may initiate and prosecute in the small claims division of the Superior Court any claim at law demanding an amount equal to or less than the jurisdictional limit of the small claims division. Notwithstanding applicable law, no judgment in an action initiated in the small claims division may be entered for an amount in excess of the jurisdictional limit of the small claims division. Article 1.5: Severability: If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provisions. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY MUTUAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO JURY OR COURT TRIAL. I have read and agree to the terms listed in this agreement and understand that I have the right to receive a copy of this arbitration agreement upon request. [Signature] December 22, 2024 | 