Smile Studios
Teeth Whitening
Consent Form

Offices of Consent:

940 Eastlake Parkway
Studio 14
Chula Vista, CA 91914

&

5171 Mission Center Rd.
Studio 22
San Diego, CA 92108

Informed Customer Consent

This consent form is given to you (the customer), and requires submission before any procedures with Teeth Whitening begin. It is important you read all the information on this page. Once you have read and understood all the information on this page, please complete the form below with your information. Only the person receiving service(s) (aka. the procedure(s) / treatment(s)), should be completing this consent form. Along with your information, you must also submit your eSignature (electronic signature) in the below form.

1. I understand that I will undergo teeth whitening treatment(s).

2. No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. Results will vary per patient.

3. Like any other treatment, I understand that it has some inherent risks and limitations.

4. The results achieved are often based upon the condition of your teeth at the time of the procedure.

5. 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 gums). In rare cases the use of LED’s can damage the pulp (soft tissue in the center of teeth) of teeth. Repeated teeth whitening may damage teeth.

6. I understand during the first 0-72 hours following whitening I may experience teeth sensitivity.

7. I understand whitening may cause temporary inflammation of my gums.

8. I understand that I am not being treated by a dentist, and that my teeth are not being examined for health, cavities, etc.

9. I am aware that I should be examined by a dentist prior to treatment. I have been advised by my dentist that I currently have healthy teeth and gums.

10. I understand that if I have veneers, porcelain, or other unnatural dental materials in my mouth, that these materials cannot get any whiter than their original color.

11. 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 worn teeth. I understand if I have any of these conditions I must advise my technician.

12. If you are pregnant or lactating, I understand there may be risks by undergoing this treatment and I have advised my technician that I am currently pregnant or lactating.

13. I have asked any questions concerning the treatment that I have. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement.

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 and that he/she is at least 16 years of age. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns.

By e-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, with its possible risks, complications and benefits, all my questions have been answered to my satisfaction, and I consent to undergo this Teeth Whitening treatment.