Smile Studios
Mission Valley
Teeth Whitening
Consent Form

Office of Consent:

1640 Camino Del Rio N
Suite 206
San Diego, CA 92108

INFORMED CONSENT FOR TEETH WHITENING

I. Recommended Procedure
I hereby give consent to SMILE STUDIOS to perform Teeth Whitening Procedure on me or my dependent. The nature and purpose of the procedure have been explained to me and no guarantee has been made or implied as to result. I have been given satisfactory answers to all of my questions, and I wish to proceed with the Teeth Whitening Procedure. No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. Results will vary per patient.

II. Treatment Alternatives
Alternative methods of treatment have been explained to me, such as treatment at a dental office or self-administration. However, I elect to proceed with the Teeth Whitening Procedure.

III.   Risks and Complications
I understand that there are risks and complications associated with the Teeth Whitening Procedure. These potential risks and complications include, but are not limited to, the following: 
  • During the first 0-72 hours, teeth sensitivity, gum inflammation, and tenderness 
  • Allergic reactions to the gel solution
  • Dry/chapped lips 
  • Sensitivity of teeth . 
  • Irritation to soft tissues, particularly the gums 
  • In rare cases the use of LED’s can damage the pulp (soft tissue in the center of teeth) 
  • Possible damage to teeth with repeated teeth whitening
  • Inability to exactly match tooth coloration. 
  • Changes in the shade, aesthetics, and appearance of the restoration, which may occur over time.

IV. Understandings Regarding Teeth Whitening
  • I understand that I am not being treated by a dentist, and that my teeth are not being examined for health, cavities, etc.
  • 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. 
  • 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.
  • 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.
  • If I am 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.
  • 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.