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INFORMED CUSTOMER CONSENT FOR TEETH WHITENING TREATMENT


I acknowledge that I give consent to have a Teeth Whitening treatment that is designed to whiten the color of my teeth. I am asking for assistance in the use of my teeth whitening kit, and I understand that I will be allowed to use a specially designed LED Lamp in order to accelerate the whitening process.

Results 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 fluorosis, these will be difficult to whiten. Also, if I have artificial teeth, caps, crowns, veneers, porcelain, composite or other restorative materials, I shouldn’t expect dramatic results from this treatment because the peroxide gel will not whiten (or damage) artificial dental work. Also, I am aware that my teeth will never be whiter than the white color my genes naturally allow.

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 the lips during the treatment may cause inflammation or whitening of theses areas. This is due to 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 and tingling sensation on these soft tissues 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 cause sensitivity may find that those conditions increase or prolong tooth sensitivity after the treatment.

SPOTS OR STREAKS: Some customers may develop white spots or streaks on their 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 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, tea, tobacco, red wine, colas, etc. I realize that I should not eat or drink anything except water during 60 minutes after the treatment because the gel opens the pores of my enamel and makes my teeth very 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 so I should refrain from staining agents till I stop using the pen. Only 48 hours after I conclude the touch-up pen treatment can I resume my normal habits. I understand that 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. 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, or people with a known allergy to peroxide and/or to aloe vera. People that have had braces removed should wait 6 months for cement residue to wear off before getting a teeth whitening treatment and people with a piercing or other metal objects in the oral cavity should remove them before the treatment as they may turn black. 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.

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

April 28, 2025

First Client Name

First Name*

Last Name*

Phone*
First Client Date of Birth*
First Client Information
I also give permission for my credit card on file to be charged $25 in the event I cancel or reschedule within 24 hour of my appointment.
First Client Signature*
Second Client Name

First Name*

Last Name*
Second Client Date of Birth*
Second Client Information
I also give permission for my credit card on file to be charged $25 in the event I cancel or reschedule within 24 hour of my appointment.
Third Client Name

First Name*

Last Name*
Third Client Date of Birth*
Third Client Information
I also give permission for my credit card on file to be charged $25 in the event I cancel or reschedule within 24 hour of my appointment.
Fourth Client Name

First Name*

Last Name*
Fourth Client Date of Birth*
Fourth Client Information
I also give permission for my credit card on file to be charged $25 in the event I cancel or reschedule within 24 hour of my appointment.
Fifth Client Name

First Name*

Last Name*
Fifth Client Date of Birth*
Fifth Client Information
I also give permission for my credit card on file to be charged $25 in the event I cancel or reschedule within 24 hour of my appointment.
Sixth Client Name

First Name*

Last Name*
Sixth Client Date of Birth*
Sixth Client Information
I also give permission for my credit card on file to be charged $25 in the event I cancel or reschedule within 24 hour of my appointment.
Seventh Client Name

First Name*

Last Name*
Seventh Client Date of Birth*
Seventh Client Information
I also give permission for my credit card on file to be charged $25 in the event I cancel or reschedule within 24 hour of my appointment.
Eighth Client Name

First Name*

Last Name*
Eighth Client Date of Birth*
Eighth Client Information
I also give permission for my credit card on file to be charged $25 in the event I cancel or reschedule within 24 hour of my appointment.
Ninth Client Name

First Name*

Last Name*
Ninth Client Date of Birth*
Ninth Client Information
I also give permission for my credit card on file to be charged $25 in the event I cancel or reschedule within 24 hour of my appointment.
Tenth Client Name

First Name*

Last Name*
Tenth Client Date of Birth*
Tenth Client Information
I also give permission for my credit card on file to be charged $25 in the event I cancel or reschedule within 24 hour of my appointment.
Parent or Guardian's Email Address

Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
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 Information
I also give permission for my credit card on file to be charged $25 in the event I cancel or reschedule within 24 hour of my appointment.
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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