INFORMEDCONSENTFORM IN-OFFICE TOOTHWHITENING TREATMENT INTRODUCTION

This informed consent form has been provided to me in order to make an informed decision about undergoing tooth whitening treatment. I have the right to take the necessary time to consider and ask questions about the procedure before giving my consent.

DESCRIPTION OF THE PROCEDURE:

In-Office Whitening is a procedure intended to lighten the color of my teeth using a hydrogen peroxide gel. The treatment involves applying the gel to my teeth during two or three 20-minute sessions, with the option of an additional fourth session if necessary. Throughout the treatment, a plastic retractor will be used to keep my mouth open, and measures will be taken to protect my lips, gums, cheeks, and tongue from exposure to the gel. I will also be provided with protective eyewear for my eyes.

RISKS OF TREATMENT:

I understand that the results of In-Office whitening treatment may vary due to individual factors. While natural teeth generally respond well to the treatment, it may not produce the same whitening effect on artificial teeth, such as caps, crowns, veneers, or restorative materials. Individuals with teeth affected by tetracycline use or fluorosis may experience limited improvement and may require additional treatments. Additionally, teeth with extensive fillings, cavities, chips, or cracks may not lighten significantly and may be better suited for alternative non-bleaching options. I acknowledge that the outcome of the In-Office Whitening treatment cannot be guaranteed. I understand that although my dentist/hygienist is trained in administering the In-Office Whitening system, there are inherent risks associated with the treatment.

Potential complications mayinclude:

• Tooth sensitivity: It is normal to experience mild tooth sensitivity following the treatment, which usually subsides within a few days. However, individuals with pre-existing sensitivity, exposed dentin or root surfaces, worn teeth, cracked teeth, cavities, leaking fillings, or other dental conditions that increase sensitivity may experience more prolonged sensitivity or pain.

• Regress of tooth shading: After the whitening treatment, it is natural for the teeth to gradually regress in shading over time. This regression can be accelerated by exposure to staining agents. Maintaining the desired tooth shade may require additional treatments or the use of take-home trays.

I am aware that the results of the whitening treatment are not permanent, and additional treatments may be necessary to maintain the desired tooth shade. Following the treatment, it is important to avoid substances that can cause tooth discoloration, such as coffee, tea, colas, tobacco products, mustard, ketchup, red wine, soy sauce, berries, berry pie, and red sauces, for at least 48 hours.

It is important to note that this consent form does not include an exhaustive list of all possible complications. However, my dentist/hygienist has explained the basic procedures of the whitening treatment, as well as the advantages, disadvantages, risks, and known possible complications of alternative treatments. They have also addressed all my questions and concerns to my satisfaction.

By signing this informed consent form, I confirm that I have read and understood its content. I fully comprehend the potential risks, complications, and benefits associated with the tooth whitening treatment, and I consent to undergo the treatment as described by my dentist and/or their staff.

By signing below, I acknowledge that I have read and understood the entire document, and I give my permission for the In-Office whitening treatment to be performed on me.

I understand and accept that I am financially responsible for the In-Office tooth whitening treatment and any associated fees. I acknowledge that the cost of the treatment is non-refundable, regardless of the outcome or satisfaction with the results. Any additional treatments, follow-up visits, or procedures deemed necessary by my dentist/hygienist will be discussed with me, and I will be responsible for the associated costs. I confirm that I have been informed of the fees and payment policies, and I agree to fulfill my financial obligations promptly.

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