Teeth Whitening Consent Form - DS Family and Cosmetic Dentistry
  • Teeth Whitening Consent Form 

  • DaVinci TEETH WHITENING EXPECTATIONS:

    DaVinci Teeth Whitening safely removes stains caused by foods, beverages, tobacco, medicine and aging. For the ultimate whitening effect on your teeth, you have the option to perform up to 3 whitening sessions at this time.

    When whitening, you may feel a slight tingling.

    DaVinci products will not damage existing dental work.

    DaVinci products will remove stains from existing dental work but will not whiten them beyond their original color.

    White spots may appear more prevalent directly after whitening, but the contrast will lessen within 24 hours.

    Everyone’s teeth respond differently and have their own natural “stop” point for whitening results.

    Teeth may feel temporary sensitivity; sensitivity is typically minor and gone within 24 hours. You may choose to purchase a desensitizing treatment with your whitening.

    You may experience temporary gum irritation, which is more prevalent in clients that have brush abrasion from brushing teeth within 4 hours prior to whitening.

    DaVinci PRODUCT:
    DaVinci product offers enamel strengthening qualities. It is organic plant and mineral based containing no animal byproducts. Active ingredient is a Food Grade Hydrogen Peroxide.

    RECOMMENDATIONS:
    To maintain healthy teeth and gums, it is recommended that you visit your dentist on a regular basis. If you have allergies or reactions to peroxide or glycerin, teeth whitening is not recommended. If you have diabetes, heart conditions, are pregnant and/or currently breastfeeding you may want to consult with your doctor prior to using whitening products. Ask your representative for a list of ingredients if you have concerns. Any existing mouth sores may feel temporary irritation during and/or after whitening.

    *By signing below, you acknowledge that the DaVinci Laser teeth whitening process (also known as light accelerated whitening) is a self administered process and that you have read and hereby acknowledge all information within.

     
     
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  • If you are under the age of 16, parent consent is required.

     
     
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  • *Satisfaction is guaranteed at the time of service, no refunds will be given after payment of services which is deemed satisfaction of results.

    In consideration of the services provided and other good and valuable consideration, the receipt and sufficiency of which is acknowledged by signature, Patient hereby releases forever, and discharges DaVinci Teeth Whitening, LLC and any other entity offering any of these services rendered and its employees, distributors and/or wholesaler their heirs, executors, administrators, successors, and assigns of and from all action, which Patient, his/her heirs, executors, administrators and assigns or any of them hereafter can, shall or may have for any reason whatsoever, including but not limited to all actions, causes of action, damages, claims and demands arising out of service or services offered.

     
     
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