Customer Information and Consent

{When you come for your appointment, we will ask you to fill out this electronic form}

Expectations:

You may feel a slight tingling or minor blanching of the gums, this is normal and will usually disappear in less than 4 hours. Your teeth will never be whiter than your genetic traits. White spots may appear if you had braces, or have porous enamel, this will usually disappear in 8 hours. The whitening gel is PH neutral and will not damage your enamel, caps, crowns or veneers.

***Please be advised, your teeth can only be whitened to a certain shade and cannot go whiter than your genetic traits allow. ***

If you answer YES to any of the questions below or if you have not had a dental cleaning in the last 6 months, please consult your dentist prior to use.

Please complete the form below which indicates your consent:

Name

First Name

Last Name

Email Address

Phone

(###)

###

####

Age

12-18

19-30

31-45

46+

Have allergies or reactions to any ingredients in the gel

Complete ingredient information can be provided to you at the time of your appointment.

Have existing tooth decay, periodontal disease, or gingivitis

Are photosensitive or on photosensitive medications

Pregnant or breastfeeding

Under the age of 18

Have had oral surgery or extractions in the last 30 days

Wearing oral piercings (remove prior to use)

Release

In consideration of the services provided, I hereby release SunnaSmile and its employees, distributors and or dealers from all manner of actions, causes of action, which may arise from the use of any product, service, or services provided. I have been advised to consult a dentist before initial treatment. This agreement is governed by the laws of Alberta, Canada. I have read the above and certify that I have healthy teeth and gums.

Date

YYYY

How did you hear about us?

Aftercare and the Follow-up:

For the first hour after use, drink only water. For 24 hours avoid any staining food or drinks. Please review the caution statement on the in-office and home kit prior to use.

Teeth Whitening Consent Form

Customer Information and Consent

{When you come for your appointment, we will ask you to fill out this electronic form}

Please complete the form below which indicates your consent: