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. My dentist has informed me that my teeth are discolored and could be treated by in-office whitening (also known as “bleaching”) of my teeth.
In-office tooth whitening is a procedure designed to lighten the color of my teeth using a hydrogen peroxide gel. During the procedure, the whitening gel will be applied to my teeth for two to four, 15-minute sessions. 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 eye protection. 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.
I understand I may decide not to have any treatment at all. However, should I decide to undergo the treatment, I understand there are alternative treatments for whitening my teeth for which my dentist can provide me additional information. These treatments include:
I understand that the cost of my treatment is determined by my dentist. I understand that my dentist will inform me if there are any other costs associated with my treatment.
I also understand that whitening treatment results may vary or regress due to a variety of circumstances. I understand that almost all natural teeth can benefit from whitening treatments, and significant whitening can be achieved in most cases. I understand that whitening treatments are not intended to lighten artificial teeth, caps, crowns, veneers, or porcelain, composite, or other restorative materials, and that people with darkly stained yellow or yellow-brown teeth frequently achieve better results than people with gray or bluish-gray teeth. I understand that teeth with multiple colorations, bands, splotches or spots due to tetracycline use or fluorosis do not whiten as well, 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 provisional or temporaries made from acrylics may become discolored.
I understand that treatment is not recommended for patients with known sensitivity to resins, peroxides, or glycols.
I understand that the results of my Treatment cannot be guaranteed.
I understand that in-office whitening treatments are considered generally safe by most dental professionals. I understand that although my dentist has been trained in the proper use of the whitening system, the treatment is not without risk. I understand that some of the potential complications of this treatment include, but are not limited to:
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. These substances include coffee, tea, beverages, colored food items, and ALL tobacco products. I understand that there are other substances that could discolor my teeth which I should avoid during the first 48 hours after treatment. If I have any questions regarding any such substance, I understand that I can discuss its stain potential with my dentist.
The safety, efficacy, potential complications, and risks of treatment can be explained to me by my dentist, and I understand that more information on this will be provided to me upon my request. Since it is impossible to state every complication that may occur as a result of treatment, the list of complications in this form is incomplete.
The basic procedures of treatment and the advantages and disadvantages, risks, and known possible complications of alternative treatments have been explained to me by my dentist, and my dentist has answered all my questions to my satisfaction.
In signing this informed consent I am stating I have read this informed consent (or it has been read to me) I fully understand it and the possible risks, complications, and benefits that can result from the treatment, and that I agree to undergo the treatment as described by my dentist.
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Alternatives to the above treatment