Teeth Whitening

You are required to sign a consent form at your Teeth Whitening appointment.

INFORMED CONSENT TO LED TEETH WHITENING 

I have been given this information in order that I may be able to make an informed decision about undergoing a teeth whitening procedure. I am able to take as much time as I need to come to a decision on whether or not to sign this informed consent form. I am free to ask any questions about any procedure before I consent to undergo the procedure.  

I understand that I will undergo 3 (20-minute teeth whitening treatments) and 1 (10 minute vitamin booster treatment) to achieve desired results. The teeth whitening treatment is designed to lighten the color of my teeth and safely whiten stains caused by foods, beverages, tobacco, and medicine. Crystal Whitening uses a combination of a hydrogen peroxide gel and a specially designed FDA-approved LED light. 

 I understand when whitening you may feel a slight tingling. White spots on your teeth may appear more prevalent directly after whitening, but the contrast will lessen within 24 hours. Your teeth may feel temporarily sensitive; sensitivity is typically minor and gone within 24 hours. You may choose to take a pain reliever to help with the relief of sensitivity.  You may experience temporary gum irritation, which is more prevalent in clients that brush abrasions from brushing their teeth within 6 hours prior to their whitening. 

I understand that significant whitening can be achieved in the vast majority of cases, but that results cannot be guaranteed. Everyone's teeth respond differently and have their own natural stopping point for whitening results. 

Dark yellow or yellow-brown teeth tend to have better results than gray or bluish-gray teeth. I understand that multi-colored teeth, especially if stained due to tetracycline, do not whiten very well. 

I understand that when done properly, the whitening will not harm my teeth, gums, or soft tissues. However, like any other treatment, I understand that it has some inherent risks and limitations. 

I understand possible side effects can include but are not limited to an allergic reaction to the gel solution, dry/chapped lips, tooth sensitivity, and irritation of the soft tissues (particularly the gums). In some cases, direct exposure to UV lighting or LED lighting can trigger a cold sore outbreak, typically if you are already prone to cold sores. 

I understand that I am not being treated by a dentist, my technician has no dental qualifications, and my teeth are not being examined for health, cavities, etc. I am aware that I should be examined by a dentist prior to treatment. I have been advised by my dentist that I currently have healthy teeth and gums. Our products will not damage existing dental work. We can whiten stains from existing dental work but will not whiten them beyond their original color. 

If I am pregnant or nursing I have consulted with my OBGYN and have been given the approval to proceed with whitening.  

I have read and understand the pre and post-treatment instructions. I agree to follow these instructions carefully. I understand that compliance with recommended pre and post-procedure guidelines is crucial for healing, and prevention of side effects and complications as listed above. The nature and purpose of the treatment have been explained to me. I have read and understand this agreement. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. 

I release Crystal Whitening, staff, and all specific technicians from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age and/or I am a competent adult parent or legal guardian of the minor listed below. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors, and assigns. 

By signing this informed consent, I am stating that I have read the information provided in this informed consent (or it has been read to me), the procedure has been explained to me, I understand the procedure, with its possible risks, complications, and benefits, all my questions have been answered to my satisfaction, and I consent to undergo this whitening treatment. 

I understand I must be 18 years or older, or have a parent/legal guardian sign for me. 

We ask that you please reschedule, or cancel, at least 24 hours before the beginning of your appointment or you may be charged a cancellation fee of $25.00.