Client Waiver and Consent Form

Full Name *

Email *

Phone *

Date of birth *

Address

City *

State *

Postal code *

EXPECTATIONS: People with healthy teeth and gums but who have stains of a yellowish tint, seem to get the best results. Teeth and or gums may be sensitive for a short time after the process. Bleaching of the gums is a common/temporary side effect that will subside within 8 hours. Your teeth can only be as white as your genetic traits allow. Some teeth react better than others. Possible white spots or demineralization may appear on people who have had braces or who have porous enamel, but this will subside within 24 hours. The process/system we use will not damage veneers, crowns or false teeth.

Age related staining: The longer the stain has been there, the deeper embedded it is. Therefore, a follow up might be suggested in order to achieve your maximum whitening potential.

Please acknowledge the above statement by selecting Yes below. *

Yes

AFTERCARE AND FOLLOW-UP: For a minimum of 48 hours after the process, please avoid consuming coffee, tea, dark colored soda, red wine, curry, beetroot, soy sauce and other highly pigmented foods and beverages. A good rule of thumb is; if it would stain a white fabric it could re-stain your teeth. Avoid extreme food or drink temperatures. If your teeth are sensitive, you can use desensitizing toothpaste or orajel for relief. Drinking plenty of water will help curb sensitivity. Lastly, we suggest no smoking for 48 hours after your teeth whitening session.

You are welcome to return as soon as four - six weeks to further remove undesired staining, depending on your level of sensitivity. 90% of our clients report 0 sensitivity.

Please acknowledge the above statement by selecting Yes below. *

Yes

WAIVER: The suggestions provided by the Teeth Whitening Lab are in no way intended to be a substitute for your routine and regular dental visits and exams. We always suggest that you brush and floss as directed by your dentist. We are a tooth spa that solely focuses on cosmetic teeth whitening and CANNOT provide dental advice. The Teeth Whitening Lab cannot guarantee everyone 100% successful results in one visit, as everyone's teeth whiten differently. However, we do guarantee a minimal level of results. By agreeing to be serviced by the Teeth Whitening Lab you waive any liability and fully indemnify and hold harmless the Teeth Whitening Lab, it's affiliates, subsidiaries, representatives, agents, staff, and suppliers from and against all liabilities, claims, expenses, damages, and losses, including legal fees, arising out of or in connection with the services and/or facilities.

If you agree to commencing your teeth whitening, please select Yes below *

Yes

**Please let a friendly staff member know you are done. We will go over the rest of the questions together.

Starting shade: OFFICE USE *

Ending shade: OFFICE USE

Have you ever professionally whitened your teeth? *

Yes

No

If yes, how long ago? Which process? Did you experience any sensitivity?

On a normal basis would you consider your teeth sensitive? *

Yes

No

Not sure

Have you ever had braces? *

Yes, If yes there is a possibility of white spots or demineralization patterns that may appear on the surface of the teeth. It is a temporary side effect that will subside after about 48 hours.

No

Do you have any veneers, composite bonding or bridges in your forward facing teeth? *

Yes, If yes we can only restore false teeth to their original shade but never surpass that.

No

Are you allergic to carbamide, peroxide, or glycerin? *

Yes

No

Any history of seizures, triggered by lights? *

Yes

No

Do you have existing tooth decay, periodontal disease, or gingivitis? (Any pain, bleeding or swelling?) *

Yes

No

Have you had oral surgery or extractions within the last 28 days. *

Yes

No

Are you under the age of 18? If so parental consent is required. *

Yes

No

Technician *

Phone: (562) 514-8383

Teeth Whitening Lab Long Beach

638 Alamitos Avenue

Long Beach, CA 90802

BUSINESS HOURS

Tuesday - Saturday

9:00 AM - 6:00 PM

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