Client Name *

First Name

Last Name

Mobile Number *

(###)

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Have you had teeth whitening before? *

Yes

No

Please carefully read, and tick which items apply to you

Drink Coffee or Red Wine

Eat Curries or Beetroot

Smoke

Ever Taken Tetracycline

Photosensitive Drugs

Any Known Allergies

Any Metal Fillings

Have Braces or Recently Removed

Caps/Crowns/Veneers

Gum Disease

Sensitive Teeth

Any Damaged Teeth

Any Open Cavities

Currently Pregnant/Breastfeeding

Any Decaying Teeth

Recent Oral Surgery

Authorise Treatment *

I authorise staff of the Teeth Whitening Co. and other specially trained associate technicians to perform teeth whitening, using a hydrogen peroxide gel. I acknowledge that I am purchasing a self-administered teeth whitening kit that is designed to whiten the colour of my teeth. As a part of the purchase, I am asking for assistance in the use of my teeth whitening kit, and I understand that I will use a specially designed LED Lamp in order to accelerate the whitening process.

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. I am not currently taking photosensitive drugs or have any known allergies. People that have had braces removed should wait 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.

Gum/Lip Irritation *

Whitening gel that comes in contact with gum tissue or the lips during the treatment may cause inflammation or whitening of these areas. The inflammation and/or whitening of gums and lips is temporary, and the colour change should return to normal very quickly. Also, I may feel a stinging and tingling sensation on these soft tissues during the treatment if the gel has prolonged contact with them. If this occurs, it is important I notify my technician of this discomfort so they can remove any migrated gel from the exposed area. Leaving it on the soft tissue may cause a mild burn or blister.

Tooth Sensitivity *

Although uncommon, some customers can experience some tooth sensitivity during the first 24-72 hours after the whitening treatment. People with existing sensitivity, recently cracked teeth, micro-cracks, open cavities, leaking fillings, exposed roots, or other dental conditions 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. The peroxide gel does NOT cause these spots. The gel just brings the already existing calcium deposits out and makes them visible again. These usually diminish over time.

Results Guarantee *

Most natural teeth can benefit from a teeth-whitening treatment, I understand that everyones teeth are different and that results will vary. I understand that people with yellowish teeth generally get the best results and if teeth have discolouration due to tetracycline use, age or nerve damage these may not whiten. 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 artificial dental work. Also, I am aware that my teeth will never be whiter than the white colour my genes naturally allow.

Relapse *

After the treatment, it is natural for teeth colour 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 realise 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 vulnerable to staining agents. 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 to maintain the colour I desire for my teeth.

I agree to use of photos/videos of monitoring response to the treatment and/or promotional purposes *

Yes

How did you hear about us?

Instagram

Facebook

Google

Word of mouth

Other

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 and will not hold the Teeth Whitening Co, its owners, suppliers or any of its employees liable for any of the above risks that I may experience. I also certify that I have healthy teeth and gums. *

Yes

Technician has evaluated your form and answered ALL questions *

Yes

No