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Luna Beauty and Wellness

Teeth Whitening Intake & Consent Form

EXPECTATIONS
You may feel a slight tingling or minor blanching of the gums, this is normal and will usually disappear in less than 4 hours. Your teeth will never be whiter than your genetic traits. White spots may appear if you had braces, or have porous enamel, this will usually disappear in 8 hours. The whitening gel is PH neutral and will not damage your enamel, caps, crowns or veneers. Please be advised, your teeth can only be whitened to a certain shade and cannot go whiter than your genetic traits allow. 

AFTERCARE AND FOLLOW UP
For the first hour after use drink only water. Avoid any staining food or drinks for the first 24 hours. Please review the caution statement on the in-office and home kit prior to use. 

RELEASE
I, in consideration of the services provided, hereby release Luna Beauty and Wellness as well as SunnaSmile and it's employees, distributors and or dealers from all manner of actions, causes of action, which may arise from the use of any product, service or services provided. I have been advised to consult a dentist before initial treatment. I have read the above and certify that I have healthy teeth and gums. 

Today's date: September 28, 2021

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

What are your preferred pronouns? *

Referred by: *

EXCLUSIONS FOR TREATMENT 

I have allergies or reactions to any ingredients in the gel.*
No
Yes
I have existing tooth decay, periodontal disease, or gingivitis.*
No
Yes
I am photosensitive or on photosensitive medications.*
No
Yes
I am pregnant or breastfeeding.*
No
Yes
I am under the age of 18.*
No
Yes
I have had oral surgery or extractions within the last 30 days.*
No
Yes
I am wearing oral piercings (remove prior to use).*
No
Yes

If your answered yes to any of the above questions or if you have not had a dental cleaning in the last 6 months please consult your dentist prior to use.

First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information

What are your preferred pronouns? *

Referred by: *

EXCLUSIONS FOR TREATMENT 

I have allergies or reactions to any ingredients in the gel.*
No
Yes
I have existing tooth decay, periodontal disease, or gingivitis.*
No
Yes
I am photosensitive or on photosensitive medications.*
No
Yes
I am pregnant or breastfeeding.*
No
Yes
I am under the age of 18.*
No
Yes
I have had oral surgery or extractions within the last 30 days.*
No
Yes
I am wearing oral piercings (remove prior to use).*
No
Yes

If your answered yes to any of the above questions or if you have not had a dental cleaning in the last 6 months please consult your dentist prior to use.

Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information

What are your preferred pronouns? *

Referred by: *

EXCLUSIONS FOR TREATMENT 

I have allergies or reactions to any ingredients in the gel.*
No
Yes
I have existing tooth decay, periodontal disease, or gingivitis.*
No
Yes
I am photosensitive or on photosensitive medications.*
No
Yes
I am pregnant or breastfeeding.*
No
Yes
I am under the age of 18.*
No
Yes
I have had oral surgery or extractions within the last 30 days.*
No
Yes
I am wearing oral piercings (remove prior to use).*
No
Yes

If your answered yes to any of the above questions or if you have not had a dental cleaning in the last 6 months please consult your dentist prior to use.

Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information

What are your preferred pronouns? *

Referred by: *

EXCLUSIONS FOR TREATMENT 

I have allergies or reactions to any ingredients in the gel.*
No
Yes
I have existing tooth decay, periodontal disease, or gingivitis.*
No
Yes
I am photosensitive or on photosensitive medications.*
No
Yes
I am pregnant or breastfeeding.*
No
Yes
I am under the age of 18.*
No
Yes
I have had oral surgery or extractions within the last 30 days.*
No
Yes
I am wearing oral piercings (remove prior to use).*
No
Yes

If your answered yes to any of the above questions or if you have not had a dental cleaning in the last 6 months please consult your dentist prior to use.

Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information

What are your preferred pronouns? *

Referred by: *

EXCLUSIONS FOR TREATMENT 

I have allergies or reactions to any ingredients in the gel.*
No
Yes
I have existing tooth decay, periodontal disease, or gingivitis.*
No
Yes
I am photosensitive or on photosensitive medications.*
No
Yes
I am pregnant or breastfeeding.*
No
Yes
I am under the age of 18.*
No
Yes
I have had oral surgery or extractions within the last 30 days.*
No
Yes
I am wearing oral piercings (remove prior to use).*
No
Yes

If your answered yes to any of the above questions or if you have not had a dental cleaning in the last 6 months please consult your dentist prior to use.

Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information

What are your preferred pronouns? *

Referred by: *

EXCLUSIONS FOR TREATMENT 

I have allergies or reactions to any ingredients in the gel.*
No
Yes
I have existing tooth decay, periodontal disease, or gingivitis.*
No
Yes
I am photosensitive or on photosensitive medications.*
No
Yes
I am pregnant or breastfeeding.*
No
Yes
I am under the age of 18.*
No
Yes
I have had oral surgery or extractions within the last 30 days.*
No
Yes
I am wearing oral piercings (remove prior to use).*
No
Yes

If your answered yes to any of the above questions or if you have not had a dental cleaning in the last 6 months please consult your dentist prior to use.

Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information

What are your preferred pronouns? *

Referred by: *

EXCLUSIONS FOR TREATMENT 

I have allergies or reactions to any ingredients in the gel.*
No
Yes
I have existing tooth decay, periodontal disease, or gingivitis.*
No
Yes
I am photosensitive or on photosensitive medications.*
No
Yes
I am pregnant or breastfeeding.*
No
Yes
I am under the age of 18.*
No
Yes
I have had oral surgery or extractions within the last 30 days.*
No
Yes
I am wearing oral piercings (remove prior to use).*
No
Yes

If your answered yes to any of the above questions or if you have not had a dental cleaning in the last 6 months please consult your dentist prior to use.

Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information

What are your preferred pronouns? *

Referred by: *

EXCLUSIONS FOR TREATMENT 

I have allergies or reactions to any ingredients in the gel.*
No
Yes
I have existing tooth decay, periodontal disease, or gingivitis.*
No
Yes
I am photosensitive or on photosensitive medications.*
No
Yes
I am pregnant or breastfeeding.*
No
Yes
I am under the age of 18.*
No
Yes
I have had oral surgery or extractions within the last 30 days.*
No
Yes
I am wearing oral piercings (remove prior to use).*
No
Yes

If your answered yes to any of the above questions or if you have not had a dental cleaning in the last 6 months please consult your dentist prior to use.

Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information

What are your preferred pronouns? *

Referred by: *

EXCLUSIONS FOR TREATMENT 

I have allergies or reactions to any ingredients in the gel.*
No
Yes
I have existing tooth decay, periodontal disease, or gingivitis.*
No
Yes
I am photosensitive or on photosensitive medications.*
No
Yes
I am pregnant or breastfeeding.*
No
Yes
I am under the age of 18.*
No
Yes
I have had oral surgery or extractions within the last 30 days.*
No
Yes
I am wearing oral piercings (remove prior to use).*
No
Yes

If your answered yes to any of the above questions or if you have not had a dental cleaning in the last 6 months please consult your dentist prior to use.

Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information

What are your preferred pronouns? *

Referred by: *

EXCLUSIONS FOR TREATMENT 

I have allergies or reactions to any ingredients in the gel.*
No
Yes
I have existing tooth decay, periodontal disease, or gingivitis.*
No
Yes
I am photosensitive or on photosensitive medications.*
No
Yes
I am pregnant or breastfeeding.*
No
Yes
I am under the age of 18.*
No
Yes
I have had oral surgery or extractions within the last 30 days.*
No
Yes
I am wearing oral piercings (remove prior to use).*
No
Yes

If your answered yes to any of the above questions or if you have not had a dental cleaning in the last 6 months please consult your dentist prior to use.

Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

What are your preferred pronouns? *

Referred by: *

EXCLUSIONS FOR TREATMENT 

I have allergies or reactions to any ingredients in the gel.*
No
Yes
I have existing tooth decay, periodontal disease, or gingivitis.*
No
Yes
I am photosensitive or on photosensitive medications.*
No
Yes
I am pregnant or breastfeeding.*
No
Yes
I am under the age of 18.*
No
Yes
I have had oral surgery or extractions within the last 30 days.*
No
Yes
I am wearing oral piercings (remove prior to use).*
No
Yes

If your answered yes to any of the above questions or if you have not had a dental cleaning in the last 6 months please consult your dentist prior to use.

Parent or Guardian's Signature*
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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