Consultation Form Please complete and sign this form prior "*" indicates required fields Step 1 of 4 25% Date of Booking* DD slash MM slash YYYY Name* First Last Date of Birth* DD slash MM slash YYYY GenderFemaleMaleOtherAddress* Street Address City State ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Email* Mobile*How did you hear about us?*GoogleFacebookInstagramFriend Have you had any form of teeth whitening before?*YesNoWhen was your last visit to the dentist* Did you have any dental treatments?*YesNoOtherPlease rate the sensitivity of your teeth*HighMediumLowNoneDo your gums bleed when brushing or flossing?*YesNODo you have any sores in your mouth?*YesNODo you have any untreated dental issues or worn teeth?*YesNOOtherDo you have any crowns, veneers or bridges?*YesNOOtherAre your teeth discolored due to trauma, medication or genetic disorder?*YesNOOtherDo you drink any of the following:* Coffee Tea Red Wine Dark Soft Drink None Do you smoke?*YesNo Are you pregnant?*YesNoAre you currently breastfeeding?*YesNoAre you allergic to Latex, Peroxide, Carbomide or Glycerin?*YesNoOther Discount Code Is This A Group Booking? What Is The Name of Person Who Placed The Booking Is This For A Special Occasion?WeddingAnniversaryNight outOtherDate of Special Occasion DD slash MM slash YYYY INFORMATION CLIENT CONSENT FOR TEETH WHITENING TREATMENT:* I agree to the below terms and conditions.GENERAL: I acknowledge that I am purchasing a self-administered teeth whitening kit that is designed to whiten the colour of my teeth. As a part of the purchase, I am asking for assistance in the use of my teeth whitening kit, and I understand that I will be allowed to use a specially designed LED Lamp in order to accelerate the whitening process. Most natural teeth can benefit from a teeth-whitening treatment, I understand that everyone’s teeth are different and that results will vary. I understand that people with yellowish teeth generally get the best results and that if my teeth have spots due to tetracycline use (grayish tint) or fluorosis, these will be difficult to whiten. Also, if I have artificial teeth, caps, crowns, veneers, porcelain, composite or other restorative materials, I shouldn’t expect dramatic results from this treatment because the peroxide gel will not whiten (or damage) artificial dental work. Also, I am aware that my teeth will never be whiter than the white colour my genes naturally allow. Potential risks although whitening treatments are generally safe, I understand that some of the potential complications of this treatment include, but are not limited to: u000b GUM/LIP IRRITATION: Whitening gel that comes in contact with gum tissue or the lips during the treatment may cause inflammation or whitening of these areas. This is due to inadvertent exposure of small areas of those tissues to the whitening gel. The inflammation and/or whitening of gums and lips is transient, and the colour change of the gum tissue should reverse within 30 minutes. I may feel a stinging and tingling sensation on these soft tissues during the treatment if the gel comes in contact with them. u000b TOOTH SENSITIVITY: Although uncommon, some customers can experience some tooth sensitivity during the first 24 hours after the whitening treatment. People with existing sensitivity, recently cracked teeth, micro-cracks, open cavities, leaking fillings, exposed roots, or other dental conditions that cause sensitivity may find that those conditions increase or prolong tooth sensitivity after the treatment SPOTS OR STREAKS: Some customers may develop white spots or streaks on their teeth due to calcium deposits or flourosis which are already occurring in the teeth. The peroxide gel does not cause these spots. The gel just enhances the already existing condition and makes them visible. These usually diminish over time generally 1-24 hours. u000bu000bRESULTS: I understand teeth whitening results are subjective and each individual is different and results cannot be guaranteed. I understand teeth whitening is a cosmetic process which bleaches the stains on the surface of my teeth and will not change my enamel colour or improve intrinsic stains like dead nerves or tetracycline stains.u000b RELAPSE: After the treatment, it is normal for teeth colour to regress somewhat over time. This is natural and should be very gradual, but it can be accelerated by exposing the teeth to various staining agents, such as coffee, tea, tobacco, red wine, colas, etc. I realize that I should not eat or drink anything except water during 60 minutes after the treatment and avoid staining foods for 24-48 hours because the gel opens the pores of my enamel and makes my teeth very vulnerable to staining agents. I have received and will follow the aftercare. I understand that the results of the treatment are not intended to be permanent and that secondary, repeat or touch-up treatments may be needed for me to maintain the result. u000b ELIGIBILITY: I understand that this treatment CANNOT be used by pregnant or breast feeding women, people under the age of 16, people with gum disease, open cavities, leaking fillings, or other dental conditions, or people with a known allergy to peroxide and/or to any ingredient listed on the packaging of the product. I am not currently taking photoreactive drugs or have consulted with my physician about the use of an LED accelerator lamp with these treatments (Chlorthiazide, Hydrochlorothiazide, Chlorthalidone, Naprosyn, Oxaprozin, Nabumetone , Pirozicam, Doxycycline, Ciprfloxacin, Ofloxacin, Psoralens, Democlocyline, Norfloxacin, Sparfloxacin, Sulindac, Tetracycline, St. John’s Wart, Isotretinoin, Tretinoin). People that have had braces removed should wait for cement residue to wear off before getting a teeth whitening treatment and people with a piercing or other metal objects in the oral cavity should remove them before the treatment as they may turn black. If I feel a sharp pain on a particular tooth during the treatment I should stop the treatment and contact my dentist since this could be a sign of a pre-existing dental condition that requires attention. The treatment is not recommended for persons who have had lip filler or cosmetic tattoo within two weeks prior to the treatment.u000b By signing this document, I indicate that I am not ineligible as per the criteria listed above or any other condition which may make me ineligible for the treatment, that I have read and fully understand this entire document including the possible risks, complications and benefits that can result from the treatment, and that I am performing this treatment under my own responsibility and will not hold Teeth Whitening Melbourne, its owners, suppliers or any of its employees liable for any of the above risks that I may experience. I also certify that I have healthy teeth and gums.Today's Date:* DD slash MM slash YYYY Signature
