Teeth Whitening Consultation and Consent Form

1. Client Demographic Information *

First Name *

Last Name *

Address Line 1 *

Address Line 2

Email *

Phone Number *

Select Gender (Optional)

Birthday

Referred By

Medical History & Oral Analysis

2. Are you currently under the care of a dentist or doctor?

YesNo

3. If "Yes" please specify4. Do you have any of the following conditions? Please answer truthfully, this ensures your treatment is safe and effective5. If "Yes" to any of these including current medication or "Other Medical Condition", please specify

Contraindication Check

Please read carefully. Some conditions listed below are absolute contraindications, meaning treatment cannot be carried out under any circumstances. Others are relative contraindications, meaning treatment may still be possible but requires adjustment, additional precautions, or postponing the procedure.

Declaring these honestly is essential to protect your safety, prevent complications, and ensure the practitioner can choose the safest and most effective treatment approach.

6. Please tick all that apply:

Untreated cavities or active tooth painActive gum disease or severe gum recessionOral infection, ulcer, or open lesionRecent extraction/oral surgeryKnown allergy to whitening agentsPregnancy or breastfeeding without dental clearanceNone of the above

7. Treatment Selection - Please select the treatment you're booked for:

StandardPremiumUltraTop Up (30 Minutes Session)

8. Have you had any dental/whitening treatment within the last 6 weeks?9. Date of scheduled appointment. *

Client's Consent (Mandatory)

Photographs are taken before and after treatment for medical documentation and client records.

10. Client Consent (Mandatory) Please confirm each statement: *

I confirm that I have read, understood, and agree to follow the pre- and post-treatment information guide provided with this consultation and consent form.I confirm that the information I have provided is accurate, and I have disclosed all relevant medical and dental history.I understand the possible temporary side effects including sensitivity, gum irritation, and temporary discomfort.I understand that whitening results vary between individuals and depend on existing tooth shade and lifestyle factors.I understand that crowns, veneers, fillings, and other restorations may not whiten in the same way as natural teeth.I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction.I consent to photographs being taken for my medical record, with optional separate consent for marketing below.I consent to the processing of my personal data in accordance with the clinic's privacy policy and understand I can withdraw consent at any time.

11. Photo & Marketing Consent. *

I consent to my photos being used anonymously for training or educational purposes.I consent to my photos being used on social media/marketing.I do not consent to any use of my photos beyond my medical record.I consent to receive emails with offers and updates.

12. Please sign and date to confirm that you have read, understood, and agree to the statements above. *

I agree to use electronic records and signatures.12. Customer's Signature

Draw signature

Customer SignatureTimestamp captured on sign

Signature Date13. Client's Name *I agree to use electronic records and signatures.14. Employee's Signature

Draw signature

Employee SignatureTimestamp captured on sign

Employee Signature Date15. Employee's Name

Note: Customers will not see the employee signature field when filling form online.

Practitioner Notes (For Internal Use Only)

Assessment:Shade Before Treatment:Shade After Treatment:Batch Number & Expiry Date:Treatment Given / Units Used:Post-Treatment Comments:

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Teeth Whitening Consultation & Consent Form

Teeth Whitening Consultation & Consent Form