I have elected, by my own decision, to have a teeth whitening procedure.
The procedure, including nature and purpose, has been explained to me before
undergoing the teeth whitening procedure.
~I understand any and all aftercare associated with the process of teeth whitening and intend to follow the aftercare procedures provided to me.
~I understand and acknowledge any risks or complications associated with the procedure as they have been explained to me.
~I have been given the opportunity to ask questions regarding any risks, complications, or benefits associated with the procedure.
~I understand that a teeth whitening must be performed on my real and natural teeth and that a false tooth, crown, cap. veneers, or porcelain is not advised as a good candidate for teeth whitening.
~I attest that I am over the age of 18 and I am not under the influence of drugs or alcohol.
~l attest that I am not pregnant or nursing and will disclose if I am pregnant or nursing before each teeth whitening procedure.
~I understand that teeth whitening is not permanent and that I may need to receive multiple treatments to achieve my desired results.
~I understand that teeth whitening results may vary and that my payments were rendered for the service and not the individual results.
~I understand that cracks, cavities, chips, or multiple fillings in my teeth are counter-indications for teeth whitening and I should seek an alternative procedure.
~I understand that any whitening procedures can result in variations in color across my teeth including splotches and uneven whitening due to various contributing factors.
~I understand that the whitening process may affect my tooth enamel.
~I agree to inform the technician regarding any discomfort that I may feel during the procedure.
~I attest that I have given an accurate account of my medical history, including any allergies or prescription drugs that I am currently taking or intend to take.
With my signature below, I attest that I have read and fully understand this consent form and all details from above. I have provided accurate information concerning my medical history including medications that I take or any medical procedures I intend to undergo or prescriptions I intend to take. By signing below, I assume all and full responsibilities for any risks or injuries, losses, side effects damages, that may occur as part of the procedure. I will not hold my teeth whitening technician (signature below) responsible for any conditions present at the time of treatment but not disclosed that may affect the treatment.
