RADIANT WHITE CONSENT FORM

INFORMED CONSENT FOR TEETH WHITENING

Following full review of this form, I am able to make an informed decision about undergoing teeth whitening procedure.

I can take as much time as I need to come to a decision whether or not to sign this informed consent form. 

I am free to ask any questions about the teeth whitening procedure prior to receiving the procedure.

I understand that teeth whitening may take up to four 20-minute sessions to achieve desired results. 

§  The teeth whitening treatment is designed to lighten the color of your teeth and

                    safely whiten stains caused by foods, beverages, tobacco, and medicine. RADIANT WHITE 

                    uses a combination of a hydrogen peroxide gel and a specially designed FDA approved LED 

                    light.

 I understand when whitening I may feel a slight tingling.

§  White spots on your teeth may appear more prevalent directly after whitening, but the contrast will lessen within 24 hours.

 I understand my teeth may feel temporarily sensitive; sensitivity is typically minor and gone within 24 hours.

§  You may choose to take an Advil to help with relief of sensitivity. You may experience temporary gum irritation, which is more prevalent in clients that have toothbrush abrasion from brushing teeth within 6 hours prior to whitening.

 I understand that significant whitening can be achieved in the vast majority of cases, but that results cannot be guaranteed.

§  Everyone's teeth respond differently and have their own natural stopping point for whitening results. Dark yellow or yellow-brown teeth tend to have better results than gray or bluish-gray teeth. Multi-colored teeth, especially if stained due to tetracycline, do not whiten very well. 

I understand that when done properly, the whitening will not harm my teeth, gum tissue or soft tissue.

§  Like any other treatment, this procedure has some inherent risks and limitations. 

I understand possible side effects can include but are not limited to: allergic reaction to the gel solution, dry/chapped lips, tooth sensitivity and irritation of the soft tissues (particularly the gum tissue). 

§  In some cases, direct exposure to UV lighting or LED lighting can trigger a cold sore outbreak, typically if you are already prone to cold sores. 

I understand that I am not being treated by a dentist, RADIANT WHITE is NOT qualified to examine my teeth for health, cavities, etc. 

§  It is imperative to your oral health that a dentist provides a thorough oral examination prior to procedure. *I have been advised by my dentist that I currently have healthy teeth and gums. * Our products will not damage existing dental work. We can whiten stains from existing dental work but will not whiten them beyond their original color. 

If I am pregnant or nursing, I have consulted with my OBYN and have been given the ok to proceed with whitening.  

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 my questions have been answered to my satisfaction and I consent to the terms of this agreement. 

I release RADIANT WHITE from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age and/or I am a competent adult parent or legal guardian of the minor listed below. 

This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors, and assigns. 

By signing this informed consent, I am stating that I have read the information provided in this informed consent or it has been read to me.  The procedure has been explained to me. I understand the procedure, all possible risks, complications, and benefits.  All my questions have been answered to my satisfaction, and I consent to receive this whitening treatment. 

PHOTO CONSENT

I grant permission to RADIANT WHITE for the use of my photograph(s), or electronic media images, in any presentation of any kind and social media outlets. I understand that I may revoke this authorization at any time by notifying RADIANT WHITE in writing. The revocation will not affect any actions taken before the receipt of this written notification. Images will be stored in a secure location and only authorized staff will have access to them. They will be kept as long as they are relevant and after that time destroyed or archived.  

I understand I must be 18 years or older or have a parent/legal guardian sign for me. 

We ask that you please reschedule, or cancel, at least 24 hours before the beginning of your appointment or you may be charged a cancellation fee of $50.00. 

PAYMENT IS DUE AT THE TIME OF SERVICE