WP E-Signature by Approve Me - Sign Documents Using WordPress -

Led Teeth Whitening Consent Form

You have a right to be informed about your condition and its treatment, so that you may decide whether
or not to undergo this procedure after knowing the risks and hazards involved. This disclosure is not
meant to scare or alarm you; it is simply an effort to make you better informed so you may give, or
withhold, your consent for treatment.

1. I understand that I will undergo Teeth Whitening treatment(s) using a gel solution and a LED (Light Emitting Diode) device.

2. I understand that multiple treatments may be necessary to achieve desired results. Treatments can take from 30 minutes up to one hour. Additional treatments may be necessary to maintain desired results. No guarantee, warranty, or assurance has been made to me as the results that
may be obtained. Results will vary per patient. I agree to adhere to all safety precautions and regulations during the treatment.

3. Possible Side Effects can include but are not limited to: Allergic reaction to the gel solution, 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). Repeated teeth whitening may damage teeth.

4. 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.

5. I am aware that I should be examined by a dentist prior to treatment. I will advise my technician if I had/have any cavities or other dental work in my mouth.

6. I understand that if I have veneers, porcelain, or other dental materials in my mouth, that these materials cannot get any whiter than their original color.

7. 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 warn teeth. I understand if I have any of these conditions I will advise my technician.

8. If I am pregnant I understand that I may receive the LED Teeth Whitening service, however, I must first consult with my doctor.

9. 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.

10. 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 release Beauty Box SF, staff, and specific technicians from liability associated with the procedure. I certify that I am competent adult of at least 18 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.

Note: All prices are subject to change without prior notice.

Client’s Name (Please Print):

Date:

Time:

Leave this empty: