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Consent Form

Office of Consent
2831 Camino Del Rio South
Suite 205
San Diego, CA 92108


INFORMED CUSTOMER CONSENT FORM


   This consent form if given you to before any procedures with Teeth Whitening begin. It is important you read the form and your signature at the end signifies that you have done so.

1. I understand that I will undergo teeth whitening treatment(s).

2. No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. Results will vary per patient.

3. Like any other treatment, I understand that it has some inherent risks and limitations.

4. The results achieved are often based upon the condition of your teeth at the time of the procedure.

5. 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 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.

6. I understand during the first 24 hours following whitening I may experience teeth sensitivity.

7. I understand whitening may cause temporary inflammation of my gums.

8. 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.

9. 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.

10. 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.

11. 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 must advise my technician.

12. We cannot see pregnant or lactating women. This is company policy and there are no exceptions.

13. If I am provided with a home whitening treatment kit, I will follow the instructions provided by my technician.

14. I have read and understand the pre- and post-treatment instructions. I have asked any questions concerning the treatment that I have. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement.

15. I release San Diego’s Teeth Whitening Center, staff, and all specific technicians from liability associated with the procedure for my non-compliance with any of the precautions and advice provided in this consent form.

ACKNOWLEDGEMENTS OF COVID-19 & OTHER RISKS


Holder fully understands that: (a) the novel coronavirus SARS- CoV-2 and any resulting disease (together with any mutation, adaptation, or variation thereof, "COVID-19") is an extremely contagious disease and that there is risk in any public place of contacting it. Holder still wishes to proceed with the teeth whitening process.

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 e-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.