Tooth Whitening Consent Form

Please fill out the following form to help us understand your physical condition.

First Name

Email Address

Date of Birth

Last Name

Phone

Sex

Male

Female

Street Address

Street Address Line 2

City

Postal / Zip code

Region/State/Province

Emergency Contact

Emergency Contact Phone

I would like to be added to your email list for specials and discounts.

How did you hear about us?

Do you have any allergies?

Yes

If yes, please explain:

Do you have sensitive teeth?

Yes

If yes, please explain:

Description Of The Procedure

In-Office Whitening is a procedure designed to lighten the color of your 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.

During the procedure the whitening gel will be applied to my teeth for two or three 20-minute sessions, with an optional fourth 20-minute session. During the entire treatment, a plastic retractor will be placed in my mouth to help keep it open and the soft tissues of my mouth (i.e. my lips, gums, cheeks, and tongue) will be covered to ensure they are not exposed to the gel.

Lip balm may also be applied as needed and I will be provided protective eyewear for my eyes. After the treatment is completed, the retractor and all gel and tissue coverings will be removed from my mouth. Before and after the treatment, the shade of my upper-front teeth will be assessed and recorded.

This information has been given to me so that I can make an informed decision about having my teeth whitened. I may take as much time as I wish to make my decision about signing this informed consent form. I have the right to ask questions about any procedure before agreeing to undergo the procedure. I would like to have my teeth lightened via the "in-office" technique.

I understand that In-Office whitening treatment results may vary or regress due to a variety of circumstances. I understand that In-Office Whitening treatments are not inteneded to lighten artificial teeth, caps, crowns, veneers or porcelain, composite or other restorative materials and that people with stained teeth.

I understand that teeth with multiple colorations, bands, splotches or spots due to tetracycline use or fluorosis do not whiten as well, and may need multiple treatments or may not whiten at all. I understand that teeth with many fillings, cavities, chips or cracks may not lighten and are usually best treated with other non-bleaching alternatives. I understand that the results of my In-Office Whit

I understand that although my technician has been trained in the proper use of the In-Office Whitening system, the treatment is not without risk.

I understand that tooth sensitivity is normal and is usually mild, but it can be worse in susceptible individuals. Usually, tooth sensitivity or pain following a whitening treatment subsides after a few days, but it may persist for longer periods of time in susceptible individuals.

I understand that whitening treatment, is natural for teeth that underwent the whitening treatment to regress somewhat in their shading after treatment. This is natural and should be very gradual but it can be accelerated by exposing the teeth to various staining agents. Treatments usually involves wearing to take home tray or repeating the whitening treatment.

I understand that the results of the whitening treatment is not intended to be permanent and secondary, repeat or take-home treatments may be needed further to maintain the tooth shade I desire for my teeth. I understand that after treatment, I will be required to refrain from consuming any substances that could discolor my teeth for the first 48 hours after treatment.

Since it is impossible to state every complication that may occur as a result of whitening treatments, the list of complications in this form is incomplete. The basic procedures of thitening treatments and the advantages and disadvantages; risks and known possible complications of alternative treatments have been explained to me by my technician.

I declare that the info I’ve provided is accurate & complete

In signing this informed consent I am stating I have had this informed consent (or it has been read to me) and I fully understand it and the possible risks, complications and benefits that can results from the whitening treatment and that I agree to undergo the treatment as described by my dentist and/or their staff.

First, Last

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Your Signature

Alpha Woman Studios Cancellation Policy

Your appointment is very important. We understand that sometimes schedule adjustments are necessary. Therefore, we respectfully request at least 24 hours' notice prior to your scheduled appointment time for cancellations or rescheduling appointments.

Please notify us by e-mail if your cancellation is outside of our normal business hours or you're unable to reach us by phone at (213) 249-2613.

Any appointments cancelled/rescheduled or changed without 24 hours notice will results in a charge equal to 50% of the reserved service amount. All "No Shows" will be charged 100% of the reserved service amount.

Please remember that it is your responsibility to remember your appointment dates and times in order to prevent any missed appointments which result in cancellation fee. Not receiving an electronic notification of your appointments from us is not sufficient reason to miss an appointment if the original confirmation notification was received timely.

Full Name

Your Signature for Cancellation Policy

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Alpha Woman Studios Photo & Video Release

I hereby grant and authorize Eva/Jazmine/Deshon and Alpha Woman Studios the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures, video, and/or audio taken of me to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social networking sites and other print or digital communications without payment or any other consideration.

This authorization extends to all languages, media, formats, and markets now known or later discovered.

I waive the right to inspect or approve the finished product wherein my likeness appears, including written or electronic copy.

I hereby hold harmless and release Eva, Jazmine, Deshon, and Alpha Woman Studios from all liability, petitions, and causes of action which I, my heirs, representatives, executors, or any other persons may make while acting on my behalf or on behalf of my estate.

Full Name

Your Signature for Photo Release

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