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Jenny From the Bronze - Teeth Whitening Consent Form

This consent form is to provide general information to clients before a teeth whitening session, offer expectations, and after care instructions. Minors (under 18) must have a parent/guardian provide consent and be present the entire time of the session. If you have any questions about the consent form or the teeth whitening procedure, please contact me at jenny@jennyfromthebronze.com, via phone/text or my Facebook page.


Please verify all the details of your appointment are correct such as your address, date & time.



Cancellation Policy: Cancellations must be received at least 24 hours before your scheduled appointment. If you cancel less than 24 hours prior to your appointment, you may be charged a cancellation fee. If you do not call to cancel or do not show up for your appointment (or cancel less than 12 hours prior to your appointment), you may be charged the full rate of the appointment.

I Agree

Please note that the card used to hold your appointment is NOT being charged and NOT kept on file unless you checked that box to save for payment of services. It is only charged in the event a cancellation fee is applied. Payment methods accepted are cash, card, venmo, and zelle.

Minors: A parent or legal guardian MUST be present for any client under the age of 18. If an adult (parent or guardian) is not present, service cannot be performed. Appointment will be considered a no-show and client will be charged the rate of the appointment per the cancellation policy.

ALLERGIES: If you have any known allergies to hydrogen peroxide or peppermint, please do not continue scheduling the teeth whitening appointment. If you have any dental conditions or applications (crowns, veneers) in the front teeth (exposed when smiling), please inform me before booking so we can determine if you are eligible for teeth whitening.

Client Information And Consent

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 spots due to tetracycline use (grayish tint) or flourosis, they will be difficult to whiten. Also if I have artificial teeth, caps, crowns, veneers, porcelain, composite or other restorative materials, I should not expect dramatic results from this treatment as the peroxide gel will not whiten (or damage) artificial dental work. I am aware my teeth will never be whiter than the white color my genes naturally allow.

I Agree

Potential Risks

Although whitening treatments are generally safe, I understand that some of the potential complications of this treatment include but are not limited to:

Gum/Lip Irritation: Whitening gel that comes in contact with gum tissue or lips during treatment may cause inflammation of those areas. This is due to the 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 or tingling sensation on the soft tissue exposed 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 can cause sensitivity may find those conditions increase or prolong tooth sensitivity after the treatment. A mineral pen may be purchased through the specialist to help reduce sensitivity and remineralize the teeth faster.  


Spots or Streaks: Some customers may develop white spots or streaks on 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 more 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, teas, tobacco, red wine, colas, etc. I realize I should not eat or drink anything except water for 60 minutes after treatment. I will follow the post-care diet because the pores of my tooth enamel will remain open for 24-48 hours post-treatment and will cause my teeth to be 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. Therefore, I should refrain from staining agents until I stop using the pen. I may resume normal eating/drinking habits 24 hours after ending use of the touch-up pen. I understand 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.


I understand that while rare, allergic or adverse reactions are possible and I will not hold Jenny From The Bronze responsible for any reactions.

I Agree

I understand that if I have fillings that are breaking down, have any decay or erosion in my teeth, exposed roots due to disease, the gel may come in contact with these areas and cause sensitivity during and/or after treatment. The sensitivity will go away in 1-2 days. 

I Agree

I understand that the degree of whiteness cannot be predicted nor guaranteed. There are several factors that can impact whitening of teeth, including age, genetic predisposition and the color of teeth I was born with. Teeth that are yellow or brown will be easier to whiten than teeth that are bluish or gray.Teeth that are spotted or striped will be difficult to whiten. The gel is designed to whiten natural teeth so crowns, veneers, and caps will not whiten and will return to their original color of when they were first applied.

I Agree

I understand that proper aftercare, especially in the first 24-48 hours after my whitening treatment, is important to the overall results of my whitening treatment to preserve and/or maintain the level of whiteness achieved at the appointment.

I Agree

Photos: Before and after photos are always taken with the treatment sessions. Do you give Jenny From The Bronze permission to use your photos on social media, website or potentially for educational purposes? Photos will be of teeth/mouth only unless you allow a full face photo. Please type YES or NO in this box.


 

After Care:Do not eat or drink anything besides water for 1 hour after your appointment.

Your teeth will be most at risk for stains 24-28 hours after your teeth whitening. The pores of your enamel are still open at this time which increases your risk to re-staining during the 24-48 hour post-treatment timeframe. You will be provided a list of foods/beverages to avoid during this time (at least 24 hours), and it is listed here as well. It is up to you to adhere to this to preserve the whiteness you achieved after your whitening session.

Post Whitening diet for 24-48 hours: Avoid acidic drinks like orange juice, grape juice, red wine, stout beer, coffee, tea, energy drinks, sodas and fizzy drinks, carrots and orange fruits & vegetables, broccoli, spinach, green vegetables, chocolate, wheat bread, tomatoes and red sauces, beets, butter & margarine for 24-48 hours. Non-staining food and beverages include water, sparkling water, milk, vodka, gin, white wine, chicken, turkey, white fish, white rice, white pasta, white sauces, cauliflower, cottage cheese, potatoes with no skin, bananas. After 48 hours (recommended), you can resume to eat as you normally do. It is also recommended as ongoing habits to cut back on smoking and drinking red wine, avoid or limit acidic foods and drinks, avoid or limit extremely hot and cold liquids, and use suggested maintenance products to promote longer lasting results of your teeth whitening treatment.

 

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; people with a known allergy to peroxide and/or aloe vera gel. Any oral piercings, jewelry or metal objects must be removed before the treatment as piercings and metal objects may turn black and may impact the whitening results. 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.

If you have braces, you are not eligible for teeth whitening at this time. It is recommended to wait 6 months after braces have been removed to receive any teeth whitening treatment as the cement residue must wear off completely first.

If you have an allergy to hydrogen peroxide, you are not eligible for this teeth whitening treatment. I may have other product options available to you that you can use at home, so please contact me about those options if you would like to know more.

By signing this consent form, I indicate that I am not ineligible as per the criteria listed above, that I have read and fully understand this entire document including 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.

I Agree







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How did you hear about Jenny From The Bronze?

Do you have anything you want to add or have a question for me?

Are there any special instructions or considerations to get to your home? For example: gated community, apartment complex, parking instructions for apartments or offices, or you're on the 2nd or higher floor in an apartment? ** Please give clear instructions as needed to help me get to you. Please note that on floors 2 and above, there must be safe and easy access for me to get to you while carrying the equipment/supplies needed for your appointment.
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.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
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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