NuYu Teeth Whitening Consent

CUSTOMER INFORMATION AND CONSENT

NuYu Teeth Whitening is one of the newest, quickest, safest, and most effective over the counter teeth whitening products in the market. NuYu Teeth Whitening is guaranteed to rapidly produce a noticeably brighter and whiter smile for staining caused by coffee, tea, tabacco, and red wine along with some cases of intrinsic staining. NuYu Teeth Whitening is one of the only processes currently available that will give you such dramatic results in a very short time in an easy, convenient process without the prices typicaly associated with teeth whitening or the pain and sensitivity.

NuYu Teeth Whitening pen can be purchased separately to help maintain and improve teeth whiteness when used regularly and as directed.

WHAT TO EXPECT

Most people with healthy teeth and gums will experience no discomfort during the NuYu Teeth Whitening process. If you have any adverse reactions to whitening agents such as carbamide or hydrogen peroxide, or are not sure, please consult your dentist prior to having your teeth whitened. A tingling or slight sensitivity is normal and not harmful to your gums or enamel. Occasionally, gum or lip discomfort is experienced by particularly sensitive individuals. To prevent this, lightly coat the affected areas with Vitamin E. For teeth sensitivity it is best to use a Potassium Nitrate/Fluoride mix such as Sensodyne tooth paste. Following the treatment for those individuals who have sensitive teeth and or gums, it should subside within 24 hours.

AFTER CARE AND FOLLOW UP

For a minimum of 24 hours after the process, avoid consuming coffee, tea, dark colored soda, red wine, berries, candy, red sauces, beets, chocolate or any other foods that have a propensity to stain your teeth. A good guideline is, if it stains a white shirt, it will stain your teeth. Of course, brush and floss as directed by your dentist.
There is no definite answer as to how long the whitening effect will last; this is highly dependent on many individual factors, including the current condition and age of your teeth, diet, alcohol and tobacco consumption, genetics and dental, general and periodontal health. Whitening Specialist onsite will suggest follow up whitening sessions if necessary. The use of whitening pen 3 times after your first whitening treatment has been shown to help blend, brighten, and maintain the smile longer.

ACKNOWLEDGEMENT

I HAVE READ AND UNDERSTAND ABOVE, AND CERTIFY THAT I HAVE HEALTHY TEETH AND GUMS AND I AM NOT PREGNANT, BREASTFEEDING, UNDER THE AGE OF 18, HAVE HAD NO ORAL SURGERY IN THE PAST 28 DAYS, NOT ALLERGIC TO CARBAMIDE /HYDROGEN PEROXIDE, NOT TAKING MEDICATION THAT WOULD CAUSE ME TO BE PHOTOSENSITIVE TO LIGHT, HAVE NO EXISTING PERIODONTAL DESEASE, NO OPEN CAVITIES, AND THAT I HAVE CONSULTED MY DENTIST ABOUT TEETH WHITENING AND I AM CONSIDERED TO BE A GOOD CANDIDATE

Cancellation Policy:
Please give us a 4 hour notice or you will be charged a $25 no-show fee.

All transactions are final, and The Primping Place does not offer any money-back guarantees. You recognize and agree that you shall not be entitled to a refund for any service, under any circumstances.

DATE SIGNED: April 25, 2025

Please select who will be participating...

Adult Minor(s)
1 Minor 2 Minors 3 Minors 4 Minors 5 Minors More Minors 6 Minors 7 Minors 8 Minors 9 Minors 10 Minors

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Second Participant's Name

First Name*

Last Name*

Second Participant's Date of Birth*

Second Participant's Information

EXCLUSIONS FOR TREATMENT: (Please check those that apply) *

Have allergies or reactions to either carbamide, peroxide or glycerin.

Have existing tooth decay, periodontal disease or gingivitis.

Are photosensitive to light or on any photosensitive drugs.

Are pregnant, suspected of being, or are breastfeeding.

Under the age of 18.

Have had oral surgery or extractions within the last 28 days.

Are wearing a piercing or metal object in the oral cavity. (Please remove, as they may turn black)

None of the above

Third Participant's Name

First Name*

Last Name*

Third Participant's Date of Birth*

Third Participant's Information

EXCLUSIONS FOR TREATMENT: (Please check those that apply) *

Have allergies or reactions to either carbamide, peroxide or glycerin.

Have existing tooth decay, periodontal disease or gingivitis.

Are photosensitive to light or on any photosensitive drugs.

Are pregnant, suspected of being, or are breastfeeding.

Under the age of 18.

Have had oral surgery or extractions within the last 28 days.

Are wearing a piercing or metal object in the oral cavity. (Please remove, as they may turn black)

None of the above

Fourth Participant's Name

First Name*

Last Name*

Fourth Participant's Date of Birth*

Fourth Participant's Information

EXCLUSIONS FOR TREATMENT: (Please check those that apply) *

Have allergies or reactions to either carbamide, peroxide or glycerin.

Have existing tooth decay, periodontal disease or gingivitis.

Are photosensitive to light or on any photosensitive drugs.

Are pregnant, suspected of being, or are breastfeeding.

Under the age of 18.

Have had oral surgery or extractions within the last 28 days.

Are wearing a piercing or metal object in the oral cavity. (Please remove, as they may turn black)

None of the above

Fifth Participant's Name

First Name*

Last Name*

Fifth Participant's Date of Birth*

Fifth Participant's Information

EXCLUSIONS FOR TREATMENT: (Please check those that apply) *

Have allergies or reactions to either carbamide, peroxide or glycerin.

Have existing tooth decay, periodontal disease or gingivitis.

Are photosensitive to light or on any photosensitive drugs.

Are pregnant, suspected of being, or are breastfeeding.

Under the age of 18.

Have had oral surgery or extractions within the last 28 days.

Are wearing a piercing or metal object in the oral cavity. (Please remove, as they may turn black)

None of the above

Sixth Participant's Name

First Name*

Last Name*

Sixth Participant's Date of Birth*

Sixth Participant's Information

EXCLUSIONS FOR TREATMENT: (Please check those that apply) *

Have allergies or reactions to either carbamide, peroxide or glycerin.

Have existing tooth decay, periodontal disease or gingivitis.

Are photosensitive to light or on any photosensitive drugs.

Are pregnant, suspected of being, or are breastfeeding.

Under the age of 18.

Have had oral surgery or extractions within the last 28 days.

Are wearing a piercing or metal object in the oral cavity. (Please remove, as they may turn black)

None of the above

Seventh Participant's Name

First Name*

Last Name*

Seventh Participant's Date of Birth*

Seventh Participant's Information

EXCLUSIONS FOR TREATMENT: (Please check those that apply) *

Have allergies or reactions to either carbamide, peroxide or glycerin.

Have existing tooth decay, periodontal disease or gingivitis.

Are photosensitive to light or on any photosensitive drugs.

Are pregnant, suspected of being, or are breastfeeding.

Under the age of 18.

Have had oral surgery or extractions within the last 28 days.

Are wearing a piercing or metal object in the oral cavity. (Please remove, as they may turn black)

None of the above

Eighth Participant's Name

First Name*

Last Name*

Eighth Participant's Date of Birth*

Eighth Participant's Information

EXCLUSIONS FOR TREATMENT: (Please check those that apply) *

Have allergies or reactions to either carbamide, peroxide or glycerin.

Have existing tooth decay, periodontal disease or gingivitis.

Are photosensitive to light or on any photosensitive drugs.

Are pregnant, suspected of being, or are breastfeeding.

Under the age of 18.

Have had oral surgery or extractions within the last 28 days.

Are wearing a piercing or metal object in the oral cavity. (Please remove, as they may turn black)

None of the above

Ninth Participant's Name

First Name*

Last Name*

Ninth Participant's Date of Birth*

Ninth Participant's Information

EXCLUSIONS FOR TREATMENT: (Please check those that apply) *

Have allergies or reactions to either carbamide, peroxide or glycerin.

Have existing tooth decay, periodontal disease or gingivitis.

Are photosensitive to light or on any photosensitive drugs.

Are pregnant, suspected of being, or are breastfeeding.

Under the age of 18.

Have had oral surgery or extractions within the last 28 days.

Are wearing a piercing or metal object in the oral cavity. (Please remove, as they may turn black)

None of the above

Tenth Participant's Name

First Name*

Last Name*

Tenth Participant's Date of Birth*

Tenth Participant's Information

EXCLUSIONS FOR TREATMENT: (Please check those that apply) *

Have allergies or reactions to either carbamide, peroxide or glycerin.

Have existing tooth decay, periodontal disease or gingivitis.

Are photosensitive to light or on any photosensitive drugs.

Are pregnant, suspected of being, or are breastfeeding.

Under the age of 18.

Have had oral surgery or extractions within the last 28 days.

Are wearing a piercing or metal object in the oral cavity. (Please remove, as they may turn black)

None of the above

Parent or Guardian's Email Address

Email*

Confirm Email*

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Electronic Signature Consent*

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

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