Consultation Form

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.