Whitening Consent Form
This is a consent form for whitening your teeth. Everything we have discussed verbally is documented in this form for yours and our record.
Whitening can only be performed in a healthy mouth. We would have assessed your mouth to ensure it is healthy before commencing. However if you have any pain or other concerns regarding the health of your mouth please speak to us regarding this.
We are using hydrogen peroxide or carbamide peroxide to whiten your teeth at levels legally allowed in the European Union. You will be using whitening trays made specifically for your mouth for this procedure. If you loose or damage these trays there will be an additional cost to replace them.
Alternatives to tooth whitening:
If you would like whiter teeth there are several other options available :
-Scale & Polish or Air Abrasion – will only remove surface staining-Veneers and Crowns – involve shaving of tooth enamel and replacing with porcelain, but can change the shape as well as the colour of the smile
1- Transient tooth sensitivity may develop during treatment and your dentist may give you desensitising swabs
2- Temporary inflammation or white spots on your gums may be caused by the whitening procedure. These can cause short lived discomfort which resolves within a few hours.
3- Occasionally patchy white areas occur which equalize within 2 – 3 days.
4- Porcelain restorations such as crowns or veneers as well as white fillings will not
change colour and may need to be replaced after the whitening procedure.
It is your responsibility to follow the ‘wear’ instructions that we have provided you (please see ‘Tooth Whitening Instruction Sheet’).
There are no guarantees as to the degree of whitening of your teeth and the amount of whitening varies with the individual.
Your teeth will take approximately take 2 weeks to whiten, however you may wish to whiten your teeth for longer if your desired results are not achieved within this time period.
We will supply you with 2 weeks worth of bleach and bleaching trays. If your desired results are not achieved you will have to purchase additional bleach, at an additional cost from the practice.
It is your responsibility to inform us if you are pregnant, breast-feeding or have any known allergies/sensitivity to any bleaching products.
Any crowns, bridges or filling materials in your teeth will not bleach and may require replacement following the bleaching procedure, the charge of which is not included in the cost of the whitening treatment.
You are likely to suffer from mild sensitivity especially in the first few days. We advise you to use anti—sensitive toothpaste during the treatment e.g. Sensodyne or Colgate sensitive pro—relief. Occasional days off and loading your tray with anti—sensitive toothpaste rather than bleach may help. It is unlikely that you will suffer from severe sensitivity. Though rare, there are instances where the bleaching procedure may need to be stopped due to sensitivity, if this is the case your money will not be refunded.
Ensure you wipe away excess from the gums or gum irritation may occur.
We advise you to abstain from red wine, smoking, tea, coffee and curries during the treatment as this will hinder progress of the whitening. The consumption of the aforesaid will also determine how long the teeth will remain your desired shade.
I have read and understand the above information and the information given to me verbally by the dentist.
The risks and benefits have been explained to me and I understand them.
I understand there are no guarantees as to the degree of whitening of my
I have had the opportunity to ask questions, and my questions have been answered satisfactorily.
I do not suffer from any of the medical conditions described or from any other condition, which may result in me being unsuitable for whitening treatment.
I have received a copy of the instruction sheet for home tooth whitening.
I consent to the treatment proposed and confirm my understanding and acceptance of the associated risks outlined to me.
I agree to be responsible for payment of services rendered on my behalf.
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Signed by Nina Bal
Signed On: 8th January 2020
If you have questions about the contents of this document, you can email the document owner.
Document Name: Whitening Consent Form
Agree & Sign