Teethwhite laser whitening

The Bee's Knees - Teethwhite Laser Whitening - Client Informed Consent Form
Client Name…………………………………………………………………………… Address………………………………………………………………………………… ……………………………………………Postcode…………………………………. Date of Birth…………………………………………………………………………… Home Telephone Number……………………………………………………………. Mobile Telephone Number……………………………………………………………. Suitable time to contact………………………………………………………………. Email address…………………………………………………………………………. For office use only Date of treatment ………………………………Venue……………………………… Whitening technician…………………………… SS …………….ES……………. One day follow up call by………………………………………. One week follow up call by…………………….…. Client Consent The risks i.e. sensitivity (on rare occasions this can be extreme which may cause irritation to my gums, this would be caused by the way I have reacted to the oxygenation process) and benefits have been explained to me and I understand them. I have understood the information supplied and have had the opportunity to ask questions and they have been answered to my satisfaction. I understand and acknowledge that this treatment will be completed by a trained Teethwhite technician who is not a dentist or does not claim to be and can, therefore, not advise me on my dental health I understand that this is a cosmetic treatment and not a dental treatment. I am dissatisfied with the present colour or shade of my teeth and I have been advised that my teeth may achieve a whiter appearance using Teethwhite products correctly I have completed the medical questionnaire accurately and do not suffer from any conditions listed which may prevent me from being suitable for a whitening treatment. I consent to the treatment and accept the risks described. Signed ………………………………………………….Dated…………………………. Teethwhite Laser Whitening

Teeth whitening is one of the easiest and most cost effective procedures you can undergo to
improve your appearance. It will not harm your teeth or gums in any way.
Nearly everyone with good general and dental health is suitable for teeth whitening, however, as
with all cosmetic procedures, there are risks involved and these must be fully considered prior to
deciding to go ahead.
Teeth whitening is not a substitute for oral hygiene or dental treatment and you should continue to
brush using a fluoride toothpaste and visit your dentist for 6 monthly check ups.
The Benefits
Almost all natural teeth respond to whitening.
Most candidates experience significant lightening and some can even be described as dramatic.
However, the amount of lightening varies from person to person and can never be guaranteed or
predicted.
As a general guideline, yellow or brown staining will respond better than grey or bluish staining
which is usually caused by Tetracycline (an antibiotic taken in childhood) and younger teeth will
whiten quicker than older teeth.
The Risks
If you have fillings that are breaking down, erosion or decay in the teeth or exposed root surfaces
the gel may have direct access to the vital tissues of the teeth and cause severe sensitivity.
Such conditions need corrected before embarking on a tooth whitening treatment.
Some clients may have white spots on their teeth which may not be apparent prior to whitening or
areas of the teeth which will whiten quicker for other reasons and which may become pronounced
following the treatment. In most cases this will even out with time by continued use of your
aftercare kit.
In a small amount of cases, inflammation of and/or white spots on the soft tissue (gums) can
result from the procedure but this is temporary and will subside within 3 days. If this occurs
longer than this it may be an indication of another problem not associated with teeth whitening
and you should consult your dentist.
It is important that you complete the medical questionnaire accurately otherwise any additional
risks cannot be assessed.
General information
Your technician will assess your suitability for the treatment and advise you clearly and concisely of any issues. Unsuitable clients include (this is not an exhaustive list):-  Uncontrolled health problems such as epilepsy, asthma or diabetes  History of heart problems, kidney problems or liver problems  Clients with mouth cancer  Clients with bleeding problems  Clients with unrealistic expectations Temporarily unsuitable clients include (again this is not an exhaustive list):-  Those with significant periodontal disease (gum disease) – refer client to a dentist  Those with excessive apparent caries (cavities) – refer client to a dentist  Clients who are pregnant or breast feeding – effect on baby/foetus is not sufficiently  Those with active herpes (cold sore) – clients should wait until this clears up. You will be given the opportunity to ask any questions and to have them answered to your satisfaction before treatment. Artificial dental work such as crowns, bridges, veneers and white fillings Teeth whitening will not lighten artificial dental work any more than its original colour although it can remove surface stains from them. You should be aware that your teeth may lighten beyond any placed artificial dental products. You have two options. You can either whiten your natural teeth and have the artificial product replaced to match your new whiter smile or you can whiten (preferably with the home whitening system) slowly and stop when your artificial dental work starts to look too dark. Teeth whitening will not undermine or damage any artificial dental work. Before Treatment It would be beneficial to visit your hygienist for a scale and polish as long as it is performed more than a week before your whitening treatment. Otherwise it’s better to wait until after your treatment as your gums will be tender and more prone to bleeding following a scale and polish.

Source: http://www.the-bees-knees.co.uk/downloads/Client-Informed-Consent-Form-The-Bees-Knees.pdf