Teeth Whitening Consent Form


TEETH WHITENING is designed to lighten the color of your teeth. Significant lightening can be achieved in the vast majority of cases, but the results cannot be guaranteed. When done properly, the whitening will not harm your teeth or gums. However, like any other treatment, it has some inherent risks and limitations. These are seldom serious enough to discourage you from having your teeth whitened but should be considered when deciding to have the treatment.

During the procedure, the whitening gel will be applied to my teeth, and my teeth will be exposed to the light from the lamp for three (3), 10-15-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 either the gel or light.

Lip balm (SPF rating: 30+) may also be applied as needed, and I will be provided an ultraviolet light filter 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.

I UNDERSTAND that whitening treatment results may vary or regress due to a variety of circumstances. I understand that almost all natural teeth can be lightened from whitening treatment and that whitening treatments are not intended to lighten artificial teeth, caps, crowns, veneers, or porcelain, composite or other restorative materials and that people with stained teeth.

I UNDERSTAND that 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:

  • Tooth Sensitivity/Pain – During the first 24 hours after treatment, some patients can experience some tooth sensitivity or pain. This is normal and is usually mild, but it can be worse in susceptible individuals. Normally, tooth sensitivity or pain following a treatment subsides within 24 hours, but in some cases, it can persist for longer periods of time. People with existing sensitivity, recession, exposed dentin, exposed root surfaces, recently cracked teeth, abfractions (micro-cracks), open cavities, leaking fillings, or other dental conditions that cause sensitivity or allow penetration of the gel into the tooth may find that those conditions increase or prolong tooth sensitivity or pain after treatment.
  • Gum/Lip/Cheek Inflammation – Whitening may cause inflammation of your gums, lips, or cheek margins. This is due to inadvertent exposure of
  • Dry/Chapped Lips – The treatment involves three, 15-minute sessions during which the mouth is kept open continuously for the entire treatment by a plastic retractor. This could result in dryness or chapping of the lips or cheek margins, which can be treated by application of lip balm, petroleum jelly, or Vitamin E cream.
  • Cavities or Leaking Fillings – Most dental whitening is indicated for the outside of the teeth, except for patients who have already undergone a root canal procedure. If any open cavities or fillings that are leaking and allowing gel to penetrate the tooth are present, significant pain could result. I understand that if my teeth have these conditions, I should have my cavities filled or my fillings redone before undergoing the treatment.
  • Relapse – After the treatment, it is natural for the teeth that underwent the 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. Treatment usually involves wearing a take-home tray or repeating the treatment. I understand that the results of the treatment are not intended to be permanent, and secondary, repeat, or take-home treatments may be needed for me to maintain the tooth shade I desire for my teeth.

I UNDERSTAND the nature and purpose of the proposed procedure(s)/treatment(s)/invasive diagnostic(s), the prognosis of my medical condition with and without the proposed intervention, the risks and possible discomforts involved, the benefits of the procedure(s)/treatment(s)/invasive diagnostic(s), other effective alternatives of procedure(s)/treatment(s)/invasive diagnostic(s) (if any), and the possibilities of complications.

I UNDERSTAND that the possibility and nature of complications cannot always be accurately anticipated and, therefore, there is and can be no guarantee, either expressed or implied, as to the results of the proposed treatment(s)/procedure(s)/invasive diagnostic(s).

I HAVE PROVIDED complete and accurate medical and personal history, including current medication prescription and non-prescription, which I take, and any known drug allergies.

I WILL FOLLOW all instructions as explained and directed to me, and will permit recommended diagnostic procedures, including x-rays.

I UNDERSTAND that the practice of dentistry is not an exact science and know that guarantees have not been made to me concerning the results of the procedure.

I WAS ABLE to ask questions to the doctor about my condition and the risks of the procedure(s)/treatment(s)/invasive diagnostic(s). I have given the possible risks and complications which may happen to this procedure.

I HAVE BEEN given an opportunity to read this form and my questions have been discussed and answered to my satisfaction. I fully understand possible risks, complications, and benefits that can result from the procedure(s)/treatment(s)/invasive diagnostic(s).

I HAVE BEEN given enough information to give this informed consent. By signing this Consent Form, I understand that I have not waived any of my legal rights.


Patient Name :
Signature:

Doctor Name :
Signature

Witness Name
Signature

Parent or Guardian (if patient is minor)

Date