Printable Template Free Teeth Whitening Consent Form COST I understand that the cost of my treatment is determined by my dentist I understand that my dentist will inform me if there are any other costs associated with my treatment RISKS OF TREATMENT also understand that whitening treatment results may vary or regress due to a variety of circumstances
Possible Side Effects can include but are not limited to Allergic reaction to the gel solution 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 The take home whitening procedure that you will be using is designed to lighten the colour of the teeth using the peroxide gel in a custom fitted tray worn over the teeth The Boutique Whitening By Day should be worn for at least 1 5 hours a day The Boutique Whitening By Night and Hybrid Pro should be worn for at least 4 hours or overnight
Printable Template Free Teeth Whitening Consent Form
Printable Template Free Teeth Whitening Consent Form
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Printable Template Free Teeth Whitening Consent Form Printable Templates
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Printable Template Free Teeth Whitening Consent Form Printable Templates
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INSTRUCTIONS Avoid smoking during treatment and reduce staining foods such as tea coffee red wine etc Brush your teeth before and after bleaching Brush the trays with your normal toothbrush and tooth paste Apply no more than 1 3 to 1 2 of syringe gel per tray and wear for 30 minutes per day Use this Tooth Whitening Consent Form that contains information about the patient It also has questionnaires about the patient s current dental health This form template also has a waiver and consent section where the patient can agree to and sign in to Use Template More templates like this COVID 19 Liability Waiver
Desired results There are no guarantees as to the degree of whitening of your teeth The amount of whiteness varies with each individual Relapse Following completion of whitening pigments found in food and drinks will restain your teeth commonly called whitening relapse You may use daily whitening toothpaste available in drug stores Whitening Consent Form Baylee Dental 16850 S Hwy 441 Ste 301 Summerfield FL 34491 352 307 3006 Whitening Consent Form I understand that my professional whitening treatment cannot be guaranteed as teeth whiten differently for each individual depending on his or her genetic traits and types of stains
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Use this template Open in new tab If you are running a dental clinic that provides teeth whitening services you might be looking for a simple way to collect consent from your patients After all failing to do so might be both illegal and make your business vulnerable to lawsuits and unwanted claims DESCRIPTION OF THE PROCEDURE In Office Whitening is a procedure designed to lighten the color of my teeth using a hydrogen peroxide gel The In Office Whitening treatment involves using the gel to produce maximum whitening results in the shortest possible time
Teeth will fade back towards their original color over time and may require repeated whitening from time to time purchased at the patient s expense Sometimes the gums can go white during whitening this is reversible I have read and understand this consent form and wish to consent to and proceed with whitening treatment Fill out Teeth Whitening Consent Form within several minutes by simply following the recommendations below Choose the document template you want from our collection of legal forms Choose the Get form key to open the document and move to editing Submit all of the required boxes they will be yellow colored
Teeth Whitening Consent Form Template
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COST I understand that the cost of my treatment is determined by my dentist I understand that my dentist will inform me if there are any other costs associated with my treatment RISKS OF TREATMENT also understand that whitening treatment results may vary or regress due to a variety of circumstances
https://www.bluedivine.com/wp-content/uploads/2018/06/Teeth-Whitening.pdf
Possible Side Effects can include but are not limited to Allergic reaction to the gel solution 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
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Printable Template Free Teeth Whitening Consent Form - Whitening Consent Form Baylee Dental 16850 S Hwy 441 Ste 301 Summerfield FL 34491 352 307 3006 Whitening Consent Form I understand that my professional whitening treatment cannot be guaranteed as teeth whiten differently for each individual depending on his or her genetic traits and types of stains
