INFORMED CONSENT TO WHITENING
Date: _______________________________________________________
Client Name: _________________________________________________
INTRODUCTION
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 procedures before agreeing to undergo the procedure.
I understand that in most cases, teeth will become several shades brighter. I understand that the type of discoloration affecting my teeth, my dietary habits, maintenance and overall condition of my teeth may affect the outcome of the treatment and the term of the results.
I also understand that this procedure is optional and has not been recommended as a requirement.
DESCRIPTION OF THE PROCEDURE
Chairside tooth whitening is a procedure designed to lighten the color of my teeth using a combination of a hydrogen or hydrogen/carbamide peroxide gel and a specially designed visible LED lamp. The treatment involves using the gel and lamp in conjunction with each other to produce maximum whitening results in the shortest possible time.
During the procedure, the whitening gel will be applied to my teeth and my teeth will be exposed to the light from the LED lamp for two to four (2-4) 12 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. I will be provided a visible LED 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.
COST
My hygienist has communicated that the cost of the whitening treatment is $____ (+ $50 if mobile) and I agree to this. I understand that there may be other costs associated with my treatment, which are my responsibility. These include extra bleaching agents for maintenance as well as post treatment desensitizing agents and medication should I have post treatment sensitivity.
RISKS OF CONSENT FOR TREATMENT
I understand that:
Existing issues should be treated before undergoing a whitening procedure,
Results will vary or regress due to a variety of circumstances,
Whitening treatments are not intended to lighten artificial teeth, caps, crowns, veneers or porcelain, composite or other restorative materials, and that these types of restorations may need to be replaced at my expense to match my newly whitened teeth,
Darkly stained yellow or yellow-brown teeth frequently achieve better results than people with gray or bluish-gray teeth,
Teeth with multiple colorations, splotches, or spots due to tetracycline use or fluorosis do not whiten as well, may whiten unevenly, may require additional whitening, or may not whiten at all,
Previous orthodontic treatments may cause teeth to whiten unevenly if any resin from the treatment was not properly removed from the teeth, either due to residual resin remaining on the teeth or over polishing upon removal,
Those with porcelain fused to metal crowns, amalgams, lingual bars or implants may feel excessive heat,
Teeth with many fillings or cavities may not lighten and are usually best treated with other non-whitening alternatives,
The LED lamp emits visible LED light and all materials used in the isolation process, when properly applied, will block any exposures of soft tissues to this light,
It is recommended that those currently being treated for a serious illness or disorder (e.g. immune compromised, AIDS, etc) should consult a medical doctor before use,
Whitening treatments are not recommended for pregnant or lactating women, or those under 16 years of age,
I understand that, as in all esthetic enhancement procedures, there are variables and end results are not guaranteed, and that my hygienist will advise me of potential problems prior to commencing treatment.
I understand that chairside whitening treatments are considered generally safe by most dental professionals.
I understand that although the hygienist 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 a whitening 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, this tooth sensitivity or pain subsides within 24 hours, but in rare cases can persist for longer periods of time in susceptible individuals.
People with existing sensitivity, recession exposed root surfaces, exposed dentin, untreated caries, cracked teeth, abfractions, oral tissue injury, open cavities, leaking fillings, or other dental conditions that cause sensitivity or allow higher penetration of the gel into the tooth may find that those conditions increase or prolong tooth sensitivity or pain after whitening treatment.
Gum/Lip/Cheek Inflammation/Burn - Improper isolation during the whitening procedure may cause or result in:
(i) inflammation of your gums, lips or cheek margins due to exposure of a small area of those tissues to the whitening gel or the LED light, or
(ii) a chemical burn due to whitening gel coming in contact with soft tissue. The inflammation or burn is usually temporary and will subside in a few days, but may persist longer and may result in significant pain or discomfort, depending on the degree to which the soft tissues were exposed to the gel or LED light.
Dry/Chapped Lips - The whitening treatment involves three to four 12-minute sessions, during which time the mouth is kept open continuously with a silicone retractor which covers the lips. 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 oil.
I have read and understand the above information pertaining to the benefits and possible side effects and results of tooth whitening. I realize that my lack of cooperation as a client may adversely affect the quality of my individual whitening results. I have had the chance to ask questions and discuss my concerns. I now consent to this whitening procedure.
Client Signature____________________________________________________
Dental Hygienist Signature ___________________________________________