Consent Form

                                                                                               INFORMED CONSENT

                                                                                                               (Teeth Whitening)

Below mentioned conditions are not suitable for Teeth Whitening

• Not suitable for Pregnant or breastfeeding women

• Not suitable for known allergies to peroxides

• Not suitable for people with significant periodontal/gum disease

• Not suitable for people with fillings that may be breaking down, unfilled cavities in their teeth, active painful condition or chipped or worn teeth may be better treated by restorative procedures first.

• Not suitable for people who are younger than 16 years of age

• Patients with pacemaker, Cancer or any other active highly immune suppressive conditions

Cancellation & Rescheduling Policy

To maintain our high standard of mobile service and respect the time allocated for your transformation, the following terms apply:

• Non-Refundable Penalty: A $50 penalty fee will be charged and the rest will be refunded in the event of a cancellation.

• Rescheduling: We understand that life happens! You may reschedule your appointment with at least 24 hours' notice.

• Redeemable Credit: In the case of a successful reschedule, your $50 deposit will be fully credited toward your new appointment date.

GENERAL DESCRIPTION

• The amount of whitening varies from patient to patient and cannot be predicted or guaranteed. But in general:

• Yellow or brown teeth, surface stains, and uniformly darkened teeth are easier to whiten than gray or bluish teeth. Striped or spotted teeth are difficult to whiten.

• This Whitening System uses an effective whitening procedure that may or may not require additional whitening treatments and home care in order to reach a desired lightened shade. Additional procedures or treatments could include take-home products or additional office visits.

RISKS

• Scientific articles have shown that the materials used by us to whiten your teeth are effective and safe. It does not change the structure of teeth; it merely makes them appear whiter and brighter.

• If tooth sensitivity develops, desensitising paste, such as PROTECT home care gel may be recommended for reducing sensitivity. If sensitivity persists for more than 12 hours or is severe, contact us.

• The whitening procedure can cause temporary inflammation and white spots on your gums. In the event this happens we will immediately apply VITAMIN E oil This should resolve very quickly.

• If you have tooth sensitivity, fillings that are breaking down, decay in your teeth, erosions of the teeth, or exposed root surfaces due to periodontal disease, the peroxide may have direct access to the affected areas. These conditions need correction prior to the whitening procedure.

• The whitening procedure can be very effective at whitening the teeth, but will not change the color of fillings or crown(s) already in your teeth. For aesthetic reasons, such fillings may need changing after the whitening procedures.

• The whitening treatment plan has been reported not to be effective on some patients. We will provide our best efforts to whiten your teeth but lightening results cannot be guaranteed.

RESPONSIBILITIES

• Avoid the use of tobacco and teeth-staining foods and beverages such as: tea, coffee, red wine, colas, tomato paste, citrus and any colored drinks, (see patient take-home instructions) and dark green vegetables for 2 days after the whitening procedure.

• Never place household or commercial bleaches in your mouth.

• If you have any questions or concerns, contact our office.

GUARANTEES

• There are no guarantees as to the degree of whitening of your teeth.

• The amount of whitening varies with the individual.

• Additional whitening sessions and the use of ancillary whitening systems may be required to obtain desired results.

• In some instances the lightening effect is minimal or unapparent and will need subsequent treatments over a longer period, to be effective.

CONSENT

I consent to photographs being taken. I understand they may be used for record documentation and for illustration of my treatment.

The risks, responsibilities, and benefits have been explained to me and I understand them.

By booking the appointment I acknowledge that I have read the above information, I consent to treatment, and I assume the responsibility for the risks described above. I also acknowledge that if I cancel the appointment there is a non refundable $50 penalty.