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Teeth whitening
Let us do this part
Today's Date:
Thu Oct 8 2026 02:45
Please read and answer
Y
N
Have you had any form of teeth whitening before?
When was your last visit to a dentist / hygienist?
 
Y
N
Are your teeth sensitive to hot/cold?
Y
N
Do you have any fillings/crowns / veneers / bridges on your front teeth?

Details: 
INFORMATION FOR CANDIDATES
The safety and effectiveness of teeth whitening in general is very high. Like all cosmetic procedures, there are limitations and considerations (which will be discussed below). Success is variable and cannot be guaranteed.

CONSIDERATIONS AND CONCERNS
Problems that can occur in teeth whitening are generally infrequent, and are usually minor in nature. Please read the following information. If you are concerned about these points please ask us before signing this consent form.
1. Tooth Sensitivity - Sensitivity is usually mild, but can be worse in susceptible individuals and should normally subside in 24 hours. People with existing sensitivity, cracked teeth, cavities, leaking fillings may find these conditions increase or prolong sensitivity.
2. Gum and Soft Tissue Irritation - Protective materials are placed in the mouth to prevent this occurring. Occasionally the whitening gel may come in contact with soft tissues in which case they cause some temporary irritation and/or white spots which should resolve within 5 days.
3. Fillings and Other Dental Restorations - Tooth coloured fillings (composites), composite veneers/bondings, porcelain crowns, and/or porcelain veneers will not whiten evenly with your natural teeth or perhaps even at all. We may, however, be able to remove certain stains (e.g., tobacco) from the surface of these restorations.

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.
Client Information
I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this agreement.
Name:*
Address:
Postcode:
Date of birth:*
 
If you are under 18 your parent/guardian will be required
Age: 
Phone #:*
Email:*
Social Handle:
If you don't mind us tagging you in photos online
Signature:*