San Diego’s Teeth Whitening Center
2831 Camino Del Rio South
San Diego CA 92108
INFORMED CUSTOMER CONSENT FORM
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 whether or not to sign this informed consent form. I am free to ask any questions about any procedure before I consent to accepting treatment or undergoing any procedure.
- I understand that I will undergo teeth whitening treatment(s). The teeth whitening treatment is designed to lighten the color of my teeth and uses a combination of a hydrogen peroxide gel and a specially designed visible LED light lamp. I understand that this is a self-administered teeth whitening treatment and during the procedure, a plastic retractor is placed in my mouth to help keep it open, I will apply a whitening gel to my teeth, and a special light may be used. Before and after the treatment, the shade of my teeth will be assessed and recorded.
- I understand that multiple treatments may be necessary to achieve desired results. Treatments can take about one hour to complete. Additional treatments may be necessary to maintain desired results. No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. Results will vary per patient. I agree to adhere to all safety precautions and regulations during the treatment. I understand that this teeth whitening treatment is not intended to be permanent and secondary, repeat visits may be needed for me to maintain the tooth shade I desire for my teeth.
- I understand that significant whitening can be achieved in the vast majority of cases, but that results cannot be guaranteed. 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 that 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 also understand that teeth with many fillings, cavities, chips, etc. are usually best treated by bonding lumineers, porcelain veneers or porcelain crowns. I understand that existing issues should be treated before undergoing a whitening procedure.
- I understand possible side effects can include but are not limited to: 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. In rare cases the use of LED’s can damage the pulp (soft tissue in the center of teeth) of teeth. Repeated teeth whitening may damage teeth.
- I understand during the first 24 hours following whitening I may experience sensitivity. This sensitivity is usually mild unless my teeth are normally sensitive. With in-office whitening, this sensitivity will usually subside within 1-2 days. With take-home whitening, it may be necessary to reduce the amount of time I wear the tray or stop using it for a short time to resolve the sensitivity.
- I understand however, if my teeth are normally sensitive, whitening may make my teeth much more sensitive for an extended period of time. If my teeth are sensitive after whitening a mild analgesic such as Tylenol or Advil will usually be effective to make me more comfortable until my teeth return to normal.
- I understand whitening may cause temporary inflammation of my gums. With in-office whitening, this can be the result of gel coming into contact with the gums. A burning sensation in my gums may also occur. This is a minor problem and will subside within a few days. With take-home whitening, irritation can result from using the whitening tray when I first start whitening or using the tray too long in a row without a break. It may be necessary for me to reduce the amount of time I am wearing the tray or stop using it for a short time to resolve these gum problems. The tray may also overlap my gums, allowing the gel to contact my gums for an extended period. This problem can be resolved by not using more whitening solution as instructed.
- I understand that I am not being treated by a dentist, my technician has no dental qualifications and that 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.
- I understand that if I have veneers, porcelain, or other unnatural dental materials in my mouth, that these materials cannot get any whiter than their original color.
- I understand I am not a good candidate for this procedure if I have significant periodontal disease, fillings that may be breaking down, unfilled cavities, or chipped or worn teeth. I understand if I have any of these conditions I will advise my technician.
- We cannot see pregnant or lactating women. This is company policy and there are no exceptions.
- If I am provided with a home whitening treatment kit, I will follow the instructions provided by my technician. I will not use the product more than instructed.
- 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 are crucial for healing, 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 understand that I may choose not to receive the discussed whitening treatment at all, that other treatment options are available, and that I am free to ask about or choose alternative options that may or may not be available through San Diego’s Teeth Whitening Center.
- I release San Diego’s Teeth Whitening Center, 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 and that he/she is at least 16 years of age. 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.