Questionaire & Consent Form
Do you drink tea or coffee? ____ Do you drink red wine?____
Do you enjoy curries?____Do you eat cheeses?____
Do you drink 2 litres of water per day?____
Are your teeth heavily stained?_____
Are your teeth moderately stained?_____
Do you smoke?____ Have you taken antibiotics in the last 2 years?____
If you have answered yes more than 4 times we recommend our 30 minute program for optimum results. If you have heavy staining or you smoke, we strongly recommend you have the complete 50 minute treat to produce optimum results.
Have you had your teeth whitened in the last 12 months?____
Do you have Veneers, False Teeth, or coloured fillings?____
Do you have mouth ulsers?____
Have you had a dental examination in the last 2 years?____
If you are you pregnant, think you are or you are nursing,
you should not proceed with any teeth whitening procedure.
Please read through this consent form before proceeding.
By signing below, you the consumer agree that:
Results vary from individual to individual dependent upon type of staining that is being treated. Individuals who demonstrate a yellow hue to teeth generally respond more favorably to teeth whitening therapy than those with brown or gray hues, or those with moderate to severe conditions of fluorosis. Generally, individuals who undergo whitening therapy experience an improvement of two to six shades. Those who begin therapy already at a shade of 1 may not experience demonstrable results, as their teeth may be at their optimal shade.
Tooth whitening therapy is not appropriate for women who are pregnant or suspect they are pregnant. Therapy should be postponed until delivery of your child.
About 10% of individuals who begin teeth whitening therapy demonstrate transient tooth and/or gum sensitivity spanning a few days post treatment. If tooth/gum sensitivity continues beyond 2 weeks, I should consult my dentist. Risk of tooth sensitivity can be reduced by daily application of toothpastes containing fluoride or potassium nitrate. It is not recommended to undergo therapy for more than one hour per session. Spacing sessions every two days can also minimize occurrence of tooth sensitivity.
I understand that whitening products are intended for use on natural tooth structure only. Tooth whitening material on restorative materials such as dental composites, amalgams, gold, ceramics, or any other material, although not harmful to such materials, could create a shade discrepancy between the tooth and restoration that may result in a desire to have the restoration replaced.
I understand that the tooth whitening process can create transient white spots on teeth that represent areas that are affected by the whitening material faster than the entire tooth and can be evened out over time with continued use of whitening material.
I understand and affirm that although the bleaching trays are prepared for me, I will place the trays and any other product in my own mouth and remove them by myself. I accept all responsibility for these actions.
I confirm I was instructed to read this document, that I have read, and completely understand the above information. I will not hold MyWhiteSmile, the parent company, suppliers or any representatives of these companies responsible for any side effects should I experience any such effects. I confirm that I am not allergic to any of the materials utilized in the trays or bleach material.
Client Name (PRINT)__________________________________
Mobile Phone:________________________________________
Email:_______________________________________________
Address______________________________________________
City:___________________ State:_________ Post Code:__________
Signature:_________________________ Date:____/_____/20_____
Office Use:
Treatment: 20 Minute 30 Minute 40 Minute 50 Minute
Teeth Colour before treatment:…….
Teeth Colour after treatment:.........
Total Paid: $...................... (please circle manner of payment)
Cash DebitCard Credit Card Gift Voucher
Consultant:…………………………. Signed:……………………………
Please print this page, complete and hand to your MyWhitesmile consultant, if you can't, don't worry as your MyWhitesmile consultant will have one for you to complete on their arrival.
