Teeth Whitening Agreement &

Consent Form

TEETH WHITENING INFORMATION

1. General Information:

Teeth Whitening is designed to lighten the color of your teeth. Significant lightening can be achieved in the vast majority of cases, but the results cannot be guaranteed. When done properly, the whitening will not harm your teeth or gums. However, like any other treatment, it has some inherent risks and limitations. These are seldom serious enough to discourage you from having your teeth whitened, but should be considered when deciding to have the treatment.

2. Candidates for Teeth Whitening:

Just about anyone is a candidate for teeth whitening. However, the following cases should be considered:

• People with dark yellow or yellow‐brown teeth tend to whiten better than people with gray or bluish‐gray teeth.

• Multi‐colored teeth, especially if due to tetracycline, do not whiten very well.

• People with significant periodontal disease are not good candidates

• If you are pregnant, obtain permission from your doctor before trying the whitening procedure.

• People with minimal discoloration, (teeth that are already very white) may not see a substantial degree of whitening.

• Teeth with many fillings, cavities, chips, etc., are usually best treated by bonding, porcelain veneers or porcelain crowns. Any current restoration you have, such as, fillings, porcelain crowns, onlays and inlays cannot be whitened.

3. Types of Teeth Whitening:

• IN-OFFICE WHITENING ‐ This process can be done in one visit or may require multiple visits depending on how your teeth respond to the whitening gel. Each appointment takes approximately one to two hours (1/2‐1 hour preparation and 1 hour treatment) The advantages of In-office whitening include our doing all the work for you and in less total time than you would spend at home whitening your teeth. The disadvantages include the normal inconveniences of any dental treatment, such as, having to keep your mouth open for the duration of the appointment and the possibility of increased costs as compared to home whitening.

• TAKE-HOME WHITENING ‐ This process, which can be done anywhere and anytime, involves wearing a custom‐made whitening tray (looks like a thin, transparent mouthguard) filled with a mild whitening agent for optimal results. You should wear the gel‐filled tray from 45 minutes per day to overnight depending on the strength of the whitening agent. You should continue treatment for about one to two weeks, depending on the degree of whitening desired. The advantages of home whitening include performing the treatment when it is convenient for you with lower costs. The disadvantage to home whitening is that the success of the treatment is dependent on your commitment to wearing the whitening tray consistently for the prescribed period.

4. YOUR RESPONSIBILITIES

• WEARING YOUR WHITENING TRAY ‐ If you choose home whitening, it will only be effective if you conscientiously wear the tray for the prescribed time for the one to three weeks.

• COMPLICATIONS ‐ If you experience any severe discomfort or other problems, discontinue the whitening and contact us immediately. Most sensitivity is usually transient and disappears after one to several days.

5. Potential Problems:

• TOOTH SENSITIVITY ‐ During the first 24 hours following whitening, some patients experience transient sensitivity. This sensitive is usually mild if your teeth are not normally sensitive. With power whitening, this sensitivity will usually subside in 1‐2 days. With home whitening, it may be necessary for you to reduce the number of minutes or hours you are wearing the whitening trays or stop using if for several days to resolve the sensitivity. However, if your teeth are normally sensitive, whitening may make your teeth more sensitive for an extended period of time. Under these circumstances, you may choose to delay the whitening process until we are able to complete desensitization procedures. If your teeth are sensitive after whitening, a mild analgesic such as Tylenol or Advil will usually be effective in making you more comfortable until your tooth sensitivity returns to normal.

• GUM IRRITATION ‐ This is the result of a small amount of solution leaking under the gum protection. A burning sensation on your gums may also occur. This should resolve by itself between a few hours to a few days. You may also experience burning and /or swelling of the lips. With home whitening, irritation can result from over filling your trays causing leakage onto the gum tissue. Irritation can also occur if you are using the tray for too many hours when you first start whitening. It may be necessary for you to reduce the amount of gel placed and reduce the amount of time you are wearing the trays or stop wearing for a few days.

• EFFECT ON FILLINGS ‐ Tooth colored fillings will not whiten. If the filling matches your current color, whitening will result in mis‐matched shades with your natural teeth. You may need to have your fillings replaced to match your newly whitened teeth.

6. Completion of Treatment:

• LEVEL OF LIGHTENING – There is no totally reliable way to predict how light your teeth will whiten. With power whitening, one session usually significantly whitens your teeth. Some patients require an additional session. With home whitening, this may take two to four weeks or longer of repeated applications.

• RELAPSE ‐ Following completion of whitening, pigments found in food and drinks will re‐stain your teeth, commonly called whitening relapse. You may use daily whitening toothpaste, available in drug stores.

I have read the information provided and understand the whitening procedure. The technician at Bling & Beauty Salon has explained this procedure to me and all my questions, if any, were answered. I consent to this treatment.

R-20 Teeth Shade Guide CLIENT IN-TAKE (Below for technician Only)

Beginning Shade: ______________________________________

After Shade: ___________________________________________