Health History

If client is a minor, please complete parental/guardian signature below:

Please Read:

• 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 then gray 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.

• This Teeth Whitening system uses a blended whitening gel and a LED red/blue light, which activates the gel's components. This procedure may or may not require additional whitening in order to achieve your desired lightened shade. 2-3, 15 minute sessions are included with your service price.

• The Whitening Gel has adjusted Ph (acidity) and conditioners to reduce teeth and gum sensitivity, all teeth react differently. In the unlikelihood sensitivity occurs, it may be present for

  1-2 days. Stain Shield is available to help solve this concern. Scientific articles have shown that the materials used in teeth whitening are safe and effective. It does not change the structure of teeth; it merely helps to achieve a whiter and brighter look

• The Whitening Gel has conditioners and moisturizers in it to sooth the gums. If the gel comes in contact with them, tingling and white bumps (blanching) can occur on gums; these are not harmful in any way and will disappear in 1-2 days with normal saliva. All people's gums react differently to the whitening 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 and may cause sensitivity during and after treatment. This sensitivity will go away within 1-2 days; the Stain Shield will help this go away faster.

Guarantee:

• 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

Client Consent:

1. I have read and initialed this consent form and understand the risks and benefits explained on it. I understand it is impossible to state every risk or complication that may occur but the technician has answered all my questions to my satisfaction.

2. I have had the opportunity to ask questions regarding this procedure. 

3. I consent to treatment and I assume all responsibility for the risks described above.

4. I agree that I am the person named above