TEETH WHITENING CONSENT FORM

I agree to the following:

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Teeth whitening is designed to lighten the color of your teeth. Significant whitening can be achieved in the vast majority of cases, but the results cannot be guaranteed. When done properly, the whitening will not harm your teeth or gums. However, like any other treatment, it has some inherent risks and limitations. These are seldom serious enough to discourage you from having your teeth whitened, but should be considered when deciding to have the treatment.

Temporary tooth sensitivity may occur with this product but should dissipate in a few hours. If product comes in contact with soft tissue (including gums, lips and skin), white spots may appear. Product is not for people using photosensitive drugs, pregnant, suspected of being pregnant or nursing. Product is not for children under 12, and children under 18 must be supervised by a parent. If you have tooth decay, exposed roots, gum disease, braces, have had a recent oral surgery or other dental problems, consult your dentist before using this product. This product is not recommended if allergic to carbamide peroxide, hydrogen peroxide or glycerin. Teeth whitening is intended for natural teeth only. This product can be used with but will not whiten caps, crowns, veneers, Fillings, dentures or any other type of dental work. It is safe to use this product every 24 hours as long as teeth are not sensitive from previous use.

Aftercare:
For a minimum of 24 hours after use, avoid consuming coffee, tea, cola, or anything that would stain a white t-shirt. If you have tooth sensitivity, it will be temporary but the use of vitamin E oil or sensitivity toothpaste will bring relief immediately. It is suggested you brush and floss as directed by your dentist. To maintain your results, BleachBright maintenance products are highly recommended.

I have read the information provided and understand the whitening procedure and the risks. I consent to this treatment.