INFORMED CONSENT FORM

TOOTH WHITENING TREATMENT INTRODUCTION

 

__This information has been given to me so that I can make an informed decision about having my teeth whitened. I may take as much time as I wish to make my decision about signing this informed consent form. I have the right to ask questions about any procedure before agreeing to undergo the procedure. I would like to have my teeth lightened via {B}right 2 U.

 

DESCRIPTION OF THE PROCEDURE

 

__Whitening is a procedure designed to lighten the color of my teeth using a hydrogen peroxide or carbamide peroxide gel. Whitening treatment involves using the gel to produce maximum whitening results in the shortest possible time.

 

__During the procedure the whitening gel will be applied to my teeth between one to three timed sessions. During the entire treatment, I will be instructed on how to place a plastic or silicone retractor in my mouth to help keep it open and the soft tissues of my mouth (i.e. my lips, gums, cheeks and tongue) will be covered to ensure they are not exposed to the gel.

 

__Lip balm may also be applied as needed and I will be provided protective eye-wear for my eyes. After the treatment is completed, the retractor and all gel and tissue coverings will be removed from my mouth. Before and after the treatment, the shade of my upper-front teeth will be assessed and recorded.

 

RISKS OF TREATMENT

 

__I understand that the whitening treatment results may vary or regress due to a variety of circumstances.

 

__I understand that almost all natural teeth can be lightened from whitening treatment. I understand that whitening treatments are not intended to lighten artificial teeth, caps, crowns, veneers or porcelain, composite or other restorative materials.

 

__I understand that teeth with multiple coloration's, bands, splotches or spots due to tetracycline use or fluorosis do not whiten as well, and may need multiple treatments or may not whiten at all. I understand that teeth with many fillings, cavities, chips or cracks may not lighten and are usually best treated with other non-bleaching alternatives.

 

__I understand that the results of my whitening cannot be guaranteed.

 

__I understand that although my treatment applicator personnel has been trained in the proper use of the whitening system, the treatment is not without risk. I understand that some of the potential complications of this treatment include, but are not limited to: Tooth Sensitivity which is normal and is usually mild, but it can be worse in susceptible individuals. Usually, tooth sensitivity or pain following a whitening treatment subsides after a few days, but it may persist for longer periods of time in susceptible individuals. People with existing sensitivity, recession, exposed dentin, exposed root surfaces and large wear facets (severely worn teeth), damaged or missing enamel, cracked teeth, cavities, leaking fillings, or other dental conditions that cause sensitivity or allow penetration of the gel into the tooth may find that those conditions increase or prolong tooth sensitivity or pain after whitening treatment.

 

__I understand that white spots or streaks may develop on the teeth due to calcium deposits that naturally occur on the teeth. These spots are NOT caused by the whitening gel. These spots typically diminish over time after the teeth remineralize with your home care. After the whitening treatment, it is natural for teeth that underwent the whitening treatment to regress somewhat in their shading after treatment. This is natural and should be very gradual but it can be accelerated by exposing the teeth to various staining agents. Treatment usually involves wearing a take home tray or repeating the whitening treatment.

 

__I understand that the results of the whitening treatment is not intended to be permanent and secondary, repeat or take-home treatments may be needed further to maintain the tooth shade I desire for my teeth. I understand that after treatment, I will be required to refrain from consuming any substances that could discolor my teeth for the first 48 hours after treatment. These substances include: coffee, teas, and colas, ALL tobacco products, mustard or ketchup, red wine, soy sauce, berries, berry pie, and red sauces.

 

__Since it is impossible to state every complication that may occur as a result of whitening treatments, the list of complications in this form is incomplete. The basic procedures of whitening treatments and the advantages and disadvantages; risks and known possible complications of alternative treatments have been explained to me by my treatment applicator personnel and they have answered all my questions to my satisfaction.

 

__In signing this informed consent I am stating I have had this informed consent (or it has been read to me) and I fully understand it and the possible risks, complications and benefits that can result from the whitening treatment and that I agree to undergo the treatment.

 

PHOTO RELEASE

 

__I give consent for photos of my teeth to be used on social media platforms for promotional reasons

 

__I do NOT give consent

 

SIGNATURES

 

By signing this document in the space provided I indicate that I have read and understand the entire document and that I give my permission for the whitening treatment to be performed on me. I also certify that I have healthy teeth and gums

 

Patient: ________ Date: _____