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Teeth Whitening Consent

Allure Body and Wellness is commited to providing exceptional service in a timely manner. Unfortunately when a customer cancels without giving notice, it prevents other customers from being served. For those purposes, Allure Body and Wellness has implemented a cancellation policy that will be strictly observed. 

Cancellation and/or rescheduling requests may be submitted by phone or email. We can be reached at (267) 490-7403 or allurebodyandwellness@gmail.com. We respectfully ask that you make contact within 24 hours of your scheduled appointment time. Your $25 deposit is non-refundable and can only be used once towards a rescheduled appointment after cancellation or a no show. If a secondary no call no show were to occur, you surrender your initial deposit and must pay another deposit to schedule a new appointment.  

First Clients Name

First Name*

Last Name*

Phone*
First Clients Date of Birth*
First Clients Signature*
Second Clients Name

First Name*

Last Name*
Second Clients Date of Birth*
Third Clients Name

First Name*

Last Name*
Third Clients Date of Birth*
Fourth Clients Name

First Name*

Last Name*
Fourth Clients Date of Birth*
Fifth Clients Name

First Name*

Last Name*
Fifth Clients Date of Birth*
Sixth Clients Name

First Name*

Last Name*
Sixth Clients Date of Birth*
Seventh Clients Name

First Name*

Last Name*
Seventh Clients Date of Birth*
Eighth Clients Name

First Name*

Last Name*
Eighth Clients Date of Birth*
Ninth Clients Name

First Name*

Last Name*
Ninth Clients Date of Birth*
Tenth Clients Name

First Name*

Last Name*
Tenth Clients Date of Birth*
Parent or Guardian's Email Address

Email
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Medical History
Have you ever had an allergic reaction to hydrogen peroxide?*
Yes
No
Have you ever had an allergic reaction to vitamin E?*
Yes
No

Please list any allergies?
Are you pregnant or nursing?*
Yes
No
Do you suffer from diabetes?*
Yes
No
Do you suffer from epilepsy?*
Yes
No
Dental History

Approximate date of last dental appointment
Have you had any dental restoration work in the last 8 weeks (i.e. crowns, bridges, fillings, implants, dentures)?*
Yes
No
Are you anticipating any restoration work in the next 6 weeks?*
Yes
No
Have you had any oral surgery in the last 6 months?*
Yes
No
Do you suffer from sensitive gums?*
Yes
No
Have you used whitening products in the past?*
Yes
No

If yes, please list any negative side effect.
Photos
Do you give Allure Body and Wellness permission to take before and after pictures during you treatment?*
Yes
No
Do you give Allure Body and Wellness permission to use your photographs taken during your treatment for the purposes of advertising, promoting and education?*
Yes
No
Consent
I understand that the amount of whitening cannot be predicted or guaranteed. Teeth will not past your genetic whiteness (what you were born with). Yellow or brown teeth with surface stains whiten easier than gray teeth. Striped or spotted teeth are also difficult to whiten. Fillings veneers will whiten back to the original color they were when first placed.*
Yes
No
I understand that the whitening system may use hydrogen or carbamide peroxide and a blue light, which activates the gel's components. This procedure may or may not require additional whitening on order to achieve your desired shade.*
Yes
No
I understand that whitening gel has a ph (acidity) and conditioners that may increase tooth and gum sensitivity.*
Yes
No
I understand that if I have fillings that are breaking down, decay, erosion, or exposed root surfaces due to periodontal disease, the gel will come in direct contact with these areas and may cause sensitivity during and after treatment.*
Yes
No
I acknowledge that while rare, an allergic reaction or adverse reactions may occur and that i do not hold Allure Body and Wellness responsible.*
Yes
No
I understand that results of the whitening treatments are not intended to be permanent. That after a period, withoutproper maintenance they will revert to the original shade. I understand that after treatment, I will be required to refrain from consuming any substances that could discolor my teeth for the first 48 hours after treatment. These substance include: coffee, teas, colas, all tobacco products, colored sauces and condiments, red wine, or berries. Do not use any colored mouthwash, toothpaste or charcoal powders.*
Yes
No

This authorization will remain in effect until revoked by the patient in writing.

Guarantees
I understand that the amount of whiteness varies with each individual. There are no guarantees to the degree of whitening. We guarantee change but cannot guarantee ow much. Additional whitening sessions may be required.*
Yes
No
Consent
I have read and completed the consent form and understand the risks and benefits explained.*
Yes
No
I consent to treatment and I assume all responsibility for the risks described above.*
Yes
No
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*

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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