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Home Bleaching Consent
I understand that my professional whitening treatment cannot be guaranteed as teeth whiten differently for each individual depending on his or her genetic traits and types of stains. I also understand that my teeth whitening treatment is not intended to whiten artificial teeth, caps, crowns, veneers or porcelain, composite or other restorative materials. I understand that the longevity of my whitening results will vary based on the types of food and drink that I consume, brushing habits, and optional maintenance with other whitening maintenance products. I understand that all forms of health treatment, including teeth whitening, have some risks and limitations. Complications can occur but are infrequent and usually minor. I understand that the whitening product is designed for minimal to no sensitivity but during or after the whitening process some patients may experience sensitivity which is normal, temporary and generally mild. A mild analgesic will usually be effective in eliminating any discomfort. I understand that whitening may cause inflammation of gums, lips and or cheek margins. I may see a white film on my gums after the procedure which is a normal reaction of hydrogen peroxide which should only be temporary. Protective materials are placed in the mouth to prevent this, but despite our best effort, it can still occur. If any irritation does occur, it is generally short of duration and is mild. Rinsing with warm salt water can relieve it. Use of the product is not recommended for children under 16 or women that are pregnant or breastfeeding.
I UNDERSTAND THAT IF ANY STATEMENTS BELOW APPLY TO ME OR IF I AM UNSURE IF THEY APPLY
TO ME, THAT I SHOULD BRING IT TO MY DENTIST OR STAFF ATTENTION BEFORE CONTINUING WITH TEETH WHITENING PROCEDURES OR PRODUCTS:
□ Do you have a severe gag reflex?
□ Are you taking any medications that increase your sensitivity to sunlight or to other forms of direct light?
□ Do you wear braces or have loose crowns, broken teeth, or other unfinished dental work?
□ Have you had any oral surgery or extractions within the last 90 days?
□ Do you have existing tooth decay, untreated gingivitis or periodontal disease?
□ Are you, to your knowledge, allergic to any of the following? Hydrogen Peroxide, Glycerin, Carbomer Sorbitol, Sodium Hydroxide, EDTA(medication), Potassium Nitrate, or Silicone
I understand I should avoid eating or drinking any possible staining substances (i.e. tomato sauce, coffee, red wine and all tobacco substances) for 48 hours after the whitening treatment. I understand it is highly recommended that I, in conjunction with using teeth whitening maintenance products, maintain a minimum of 2 cleanings a year along with an annual exam. You will have the opportunity to enroll in the Smile Maintenance Program receiving free maintenance products.
I (print name) ______________________________, confirm that I have read and understand the above information.
PATIENT’S SIGNATURE ________________________________________________ DATE: _____ / _____ / _____
Staff initial __________