Client Information & Consent Form

Name________________________________________ Email_________________________________________

Address_____________________________________ Suburb_____________________Ph_________________

Client Expectations:

People with healthy teeth and gums, but have stains or a yellow tint seem to get the best results. With this treatment your teeth will never be whiter than your genetic traits (DNA).In over 95% of cases your teeth will lighten 2-8 shades, all teeth will whiten differently. Possible white spots or demineralization may appear on customers who have had braces or who have porous enamel, but this will disappear within 24 hours.

Exclusions For Treatment: Please Answer The Following Questions:

Any allergies to peroxide, glycerin, spearmint, carbopol resin, potassium hydroxide or surfactants?       YES__NO__

Do you have tooth sensitivity that is not from hot & cold food or drinks?                                                  YES__NO__

Have you had teeth whitening with a dentist, cosmetic teeth whitener or a home whitening system?     YES__NO__

Have you been to a hygienist or dentist to have a scale and clean in the last 2 weeks?                       YES__NO__

Do you have a cracked tooth, filling fallen out, or a hole with decay in any of your teeth?                       YES__NO__

Do you have periodontal disease or gingivitis (gum disease)?                                                                 YES__NO__

Do you have any caps, crowns, bridges or veneers in your front teeth?                                                 YES__NO__

Are you pregnant, suspected of being pregnant or are breastfeeding?                                                    YES__NO__

Have you had oral surgery, a root canal or tooth extraction within the last 28 days?                               YES__NO__

Do you have any severe medical condition or medical treatment i.e kidney dialysis or chemotherapy?  YES__NO__

Do you have a metal piercing in your mouth? (Please remove a metal stud as they may turn black)      YES__NO__

If I, the customer, have answered ‘YES’ to any of the above questions, and have spoken to the salon directly, yet still consent to going ahead with this treatment, I will hold them in no way accountable or responsible for any adverse reactions at any stage now or in the future.

Client Signature if they answered YES:                ___________________________________ Date ___/___/___

Pre Treatment, Aftercare and Follow-up:

Please do not brush your teeth with toothpaste or water inside 2hrs of the procedure as toothpaste fillers block the pores of your tooth, which will not allow the whitening gel to penetrate into the tooth, and water will dilute the gel.

For a minimum of 24 hours after the process, please avoid smoking, coffee, tea, coloured soft drink, red wine, curry, beetroot etc as your pores remain open for 12-24hrs.(If it stains a white shirt, then it could stain your teeth). We will provide you with an aftercare information sheet with examples of foods safe to consume following a 'white diet' for the first 24 hours.

Customer Consent:

I, the customer named above, consent to undergo the teeth whitening treatment and any other entity performing any of these services rendered and hold harmless its employees, distributors and/or wholesalers, their heir, executors, administrators, successors, and assigns of and from all action, which I shall or may have for any reason whatsoever including but not limited to all action, damages, claims and demands arising out of the service(s) provided. I waive any right whatsoever to any action or claim against any party to my whitening treatment.

I have read the above and certify that I am 16 years of age or over and have healthy teeth and gums.

Client Signature: ____________________________________  Date: ___/___/___    Time: _______ AM/PM