Teeth Whitening Consent Form
Consent and Waiver for teeth whitening services with dhesthetics
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Email *
Client Information
General information required for liability purposes.
First & Last Name *
Phone Number *
Address *
Date of Birth (Used for special promotions😉) *
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Are you over the age of 18? *
Do you consent to receiving emails from dhesthetics? *
How did you find out about dhesthetics? *
General Information & Consultation
Have you had your teeth professionally whitened before? *
If so, where did you get it done? What did you like/not like about it? (This is simply used to help me understand your expectations & needs) *
When is the last time you had you teeth whitened? *
Service Consent & Waiver
The amount of whitening cannot be predicted or guaranteed. Teeth will not whiten past your genetic whiteness (what you were born with). Yellow or brown teeth with surface stains whiten easier than grey or bluish teeth. Striped or spotted teeth are also difficult to whiten. Fillings, crowns, or veneers will whiten back to the original colour they were when first placed. *
White Teeth Brightening system uses hybrid (5% hydrogen peroxide & 20% carbamide peroxide) high intensity whitening gels & a high-density cold blue light, which activates the gels components. This procedure may or may not require additional whitening in order to achieve your desired lightened shade. *
White Teeth Brightening gel has adjusted pH (acidity) & conditioners to reduce teeth & gum sensitivity, all teeth react differently. In the unlikelihood sensitivity occurs, it may be present for 1-2 days. Scientific articles have shown that the materials used in teeth whitening are safe & effective. It does not change the structure of teeth; it merely helps to achieve a whiter & brighter look. *
White Teeth Brightening gel has conditioners & moisturizers in it to soothe the gums. If the gels come in contact with them, tingling & white bumps (blanching) can occur on gums; these are not harmful in any way & will disappear in 1-2 days with normal saliva. All people’s gums react differently to the brightening gel. *
If you have fillings that are breaking down, decay in your teeth, erosion of the teeth, or exposed root surfaces due to periodontal disease, the gel will come in direct contact with these areas & may cause sensitivity during & after treatment. This sensitivity will go away within 1-2 days. *
I agree to follow all aftercare instructions to the best of my ability to aid in my results. *
I release Danielle (dhesthetics) from all liability associated with this procedure. There are no guarantees for the length of time a results will last. I understand that I have been advised to follow the aftercare protocol from Danielle (dhesthetics) so as to avoid any adverse side effects after whitening has been completed. *
The amount of whiteness varies with each individual. There are no guarantees to the degree of whitening. *
We guarantee change, but cannot guarantee how much. *
Additional whitening sessions may be required to obtain the ultimate desired result. *
Before & after pictures are always completed with our treatments. I agree that if any pictures are taken of my teeth that they may be posted to dhesthetics Instagram/Facebook or website page & that I will be tagged where/when possible. *
I verify that I have read and understand the above statements and fully agree to them all. *
Policy Consent
I understand that any deposit provided to dhesthetics for services is NON-REFUNDABLE. The deposit may be transferred to a new appointment time if reasonable notice is given for cancellation. *
I understand that if I no-show an appointment or cancel with less than 48 hours notice, 50% of my appointment total is due prior to re-booking. *
I understand that I must provide 48+ hours notice when rescheduling a teeth whitening appointment. I understand that if I reschedule my appointment with less than 48 hours notice I will be charged a rescheduling fee of $50. *
I understand that any service rendered, completed and paid for in full by dhesthetics is NON-REFUNDABLE. *
I verify that I have read and understand the above policies and that they will apply to ALL future appointments and I agree. *
Evaluation & Medical Form
Do you have any allergies? PLEASE LIST ALL ALLERGIES *
Have you ever had an adverse reaction to any of the following? (Select all that apply) *
Required
Have you recently had any dental restorations placed? (crowns, bridges, fillings, implants or full/partial dentures) If yes, please list and include which tooth/teeth they affect. *
Are you scheduled or anticipating restoration work within the next 6 months? *
Have you recently had oral surgery? If yes, please specify when. *
When was your last dental cleaning (approx..)? *
Have you used whitening products in the past? *
If yes, did you see any results?
Clear selection
If yes, did you have any negative side effects? (sensitivity, chemical reaction, burnt tissues?) Please list all side effects.
Clear selection
Do you suffer from areas of recession or sensitive gums? *
Are you pregnant/nursing? *
Do you suffer from diabetes or epilepsy? *
Client Consent
The information I have given on this form is correct. I have not misrepresented myself nor have I withheld any medical information, surgical state or condition. *
This agreement will remain in effect for this procedure and all future teeth whitening procedures conducted by Danielle (dhesthetics). I understand that this agreement is binding and that I have read and fully understand all information above. I represent that I am over the age of 18 years. If below 18 years of age a parent or guardian must also sign a physical form in person prior to treatment. *
Please type your full name below to be used as your official signature for this document *
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