Teeth Whitening Consent form

What is the treatment?

Teeth whitening is a cosmetic dental procedure that aims to lighten the color of teeth. It involves using bleaching agents to break down stains and discolorations on the teeth, resulting in a brighter smile.

Before the treatment:

Brush and floss 

• Brush your teeth thoroughly with fluoride toothpaste every day

• Floss to remove food debris and surface buildup

Avoid certain foods and drinks

• Avoid dark-colored foods and drinks like coffee, tea, red wine, and dark berries 

• Avoid acidic foods and drinks like citrus fruits, soda, and vinegar-based products 

Get a dental cleaning

• Get a dental cleaning within six months of your treatment 

• A dental cleaning removes plaque, tartar, and surface stains, which helps the whitening products work more effectively 

Consider sensitive teeth 

• Use a prescription fluoride toothpaste from your dentist or a sensitivity toothpaste

• Take up to 600 mg of ibuprofen before your visit

Consider mouth sores or cuts 

• Talk to your dentist about healing any mouth sores or cuts before your treatment

Consider piercings 

• Take out any mouth piercings before your treatment

Treatment considerations

I understand that teeth whitening treatment results may vary.

I understand that almost all natural teeth can be lightened from in-office whitening treatment.

I understand that teeth whitening treatments are not intended to lighten the following types of teeth:

• Artificial teeth

• Caps

• Crowns

• Veneers

• Porcelain

• Composite

• Other restorative materials

I understand that teeth with the following may not lighten and are usually best treated with other non-bleaching alternatives:

• Multiple fillings

• Cavities

• Chips

• Cracks

I understand that teeth with the following may not whiten as well and may need multiple treatments or may not whiten at all:

• Multiple colorations

• Bands

• Splotches

• Spots due to tetracycline use

• Fluorosis

I understand that the results of my whitening are not guaranteed and results vary.

I understand that although my technician has been trained in the proper use of the in-office whitening system, the treatment is not without risk.

I understand that some of the potential complications of this treatment include, but are not limited to:

• Slight tingling

• Tooth Sensitivity

• Minor discomfort

• Toothache

I understand that while some tooth sensitivity is normal and should only last for a few days, the following may make my teeth more sensitive after the treatment and may make the sensitivity last longer:

• Existing sensitivity

• Tooth recession

• Exposed dentin

• Exposed root surfaces

• Severely worn teeth

• Damaged or missing enamel

• Cracked teeth

• Cavities Leaking fillings

I understand that this procedure should not be administered on me if I am:

• pregnant

• nursing

• have not seen a dentist in two years

• have unfilled holes in my teeth

• have a temporary crown

• have untreated gum disease

I understand that it is natural for teeth that underwent the whitening treatment to regress somewhat in their shading post treatment.

I understand that this is natural and should be very gradual but it can be accelerated by exposing the teeth to various staining agents such as dark colored liquids (coffee, tea, dark soda), all tobacco products, mustard or ketchup, red wine, soy sauce, berries, berry pie, and red sauces like tomato sauce.

I understand that the results of the whitening treatment is not intended to be permanent.

I understand that repeat or take-home treatments may be needed to further maintain the shade I desire for my teeth.

I understand that after treatment, I will be required to refrain from consuming any substances that could discolor my teeth for the first 24 hours after treatment. These substances include:

• dark colored liquids (coffee, tea, dark soda)

• all tobacco products

• mustard or ketchup

• red wine

• soy sauce

• berries, berry pie

• red sauces like tomato sauce.

I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment has been explained to me. I understand and acknowledge that there are risks involved with the treatment I will be receiving. Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications, and I have had the opportunity to ask questions regarding these risks and other possible complications.