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Standard Informed Consent
Professional teeth whitening techniques are designed to lighten dark; stained teeth. Clients apply an oxygenating or peroxide type material at home using one of the several techniques. While these materials have been used for this process since 1989 appear safe, infrequent side effects can occur. Tooth sensitivity or tingling is the most common side effect. Soft tissue irritation can also occur. If a client experiences these or other adverse symptoms, he/she should stop using the bleaching material, and consult their treating dentist. If the patient has any known chemical sensitivity or allergic reactions to ingredients such as flavorings, color additives, etc. please be sure to inform your dental professional.
Clients should understand that the amount of whitening and its duration might vary. While most teeth lighten to the extent desired, some do not. In some instances lightening is minimal or unapparent. In all instances, additional whitening over time may be required to maintain the lightening originally obtained.
By accepting our service, you agree that you:
- Will use the trays for the sole purpose of whitening your teeth.
- Will not use the product if you are pregnant or nursing until you have consulted with your dentist or doctor.
- Will take the impression yourself.
- Don't have loose or decayed teeth.
- Don't have loose crowns or periodontal problems (gum disease).
- Will consult with your dentist prior to use and if you experience any whitening problems.
- Acknowledge that employees/staff of Direct white and Brighter Image PTW are not dentists.
- Are not allergic to carbamide peroxide, glycerin, carbome, flavor, hydrogen peroxide, ammonium, hydroxide, and silicone.
- Client (s) agrees that all warranties and returns are the sole determination of the company and that total liability is limited to the amount paid for the service.
I have read and understand the above description of possible consequences of using professional bleaching techniques. Being fully informed, I consent to and agree to use these techniques.
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