Teeth Whitening Consent Form

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

 

I understand that multiple treatments may be necessary to achieve desired results. Treatments can take from 15-45 minutes per session. Additional treatments may be necessary to maintain desired results. Results will vary per patient. No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. 

 

I understand that once the teeth whitening treatment begins that I may stop the treatment at any time. However, once the treatment begins SOS WAX will charge me the full treatment cost with no expectation of reimbursement.

 

I agree to adhere to all safety precautions and regulations during the treatment. 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.

 

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) of teeth.

 

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. Additionally, 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.

 

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

 

I have read, understand and I consent to the terms of this agreement. By signing below, I assume any risk, harm or injury which may occur as a result from LED Teeth Whitening services and I give my permission to my technician at SOS WAX and Skincare to the services. I will hold the technician and SOS WAX and Skincare harmless of any liability and waive any claims that may result from the services.

Who is receiving the Service?

Adult (You)  Minor

Signee Information

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By clicking 'I Agree' below, you agree that you have read and agree with the terms of the waiver and that the information you provided is accurate. You furthermore agree that your submission of this form, via the 'I Agree' button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.