I understand that teeth whitening is a procedure designed to lighten the color of my teeth. The whitening treatment involves using a hydrogen peroxide gel and LED light to produce maximum whitening results in the shortest possible time.
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I understand that teeth whitening treatment results may vary.
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I understand that almost all natural teeth can be lightened from in-office whitening treatment.
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I understand that this procedure should not be administered on me if I am pregnant, nursing, have not seen a dentist in two years, have unfilled holes in my teeth, have a temporary crown, or have untreated gum disease.
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I understand that it is natural for teeth that underwent the whitening treatment to regress somewhat in their shading post treatment.
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I understand that this is natural and should be very gradual but it can be accelerated by exposing the teeth to various staining agents such as dark-colored liquids (coffee, tea, dark soda), all tobacco products, mustard or ketchup, red wine, soy sauce, berries, berry pie, and red sauces like tomato sauce.
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I understand that the results of the whitening treatment are not intended to be permanent. I understand that repeat or take-home treatments may be needed further to maintain the shade I desire for my teeth.
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I understand that after treatment, I will be required to refrain from consuming any substances that could discolor my teeth for the first 24 hours after treatment. These substances include dark-colored liquids (coffee, tea, dark soda), all tobacco products, mustard or ketchup, red wine, soy sauce, berries, berry pie, and red sauces like tomato sauce.
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I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment has been explained to me. I understand and acknowledge that there are risks involved with the treatment I will be receiving. Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications, and I have had the opportunity to ask questions regarding these risks and other possible complications.
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Client Signature
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Today's Date
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