INTRODUCTION
This information has been given to me so that I can make an informed decision about having my teeth cosmetically whitened. I may take as much time as I need to make my decision about signing this informed Consent form. I have the right to ask questions about the Perfect Ten Smile teeth whitening treatment before agreeing to undergo the procedure.
CANCELLATION POLICY
Perfect Ten Smile has a cancellation policy that may be applied. For any no show or same day cancellations, the card on file will be charged for the full amount of the selected whitening service and you will have 14 (fourteen) days to use the credit for teeth whitening for yourself. After that point the credit is no longer valid. Please notify us before 24 hours of scheduled appointment with any changes.
RESCHEDULING POLICY
Perfect Ten Smile has a rescheduling policy that limits reschedules to max 2 (two) reschedules for each visit. For any reschedules that happen after the second reschedule, the card on file will be charged for the full amount of the selected whitening service and you will have 14 (fourteen) days to use the credit for teeth whitening for yourself. After that point the credit is no longer valid.
DESCRIPTION OF THE PROCEDURE
The Perfect Ten Smile teeth whitening treatment is designed to lighten the color of my teeth using a combination of a peroxide based gel and a specially designed gel-activating whitening light. The treatment involves using the gel and light in conjunction with each other to produce the whitening action. During the procedure, the whitening gel will be applied to my teeth and my teeth will be exposed to the light from the light for up to one hour. During the entire treatment, a disposable cheek retractor or tray will be placed in my mouth to help keep it open, lip protection will also be provided as needed and I will be provided a pair of protective eyewear to use during the treatment. After the treatment is completed, the cheek retractor or tray will be removed and I will be instructed to rinse my mouth with water at the sink in the office.
Before and after the treatment, the shade of my teeth will be assessed.
ALTERNATIVE TREATMENTS
I understand I may decide not to have the Perfect Ten Smile teeth whitening treatment at all. However, should I decide to undergo the treatment, I understand there are many alternative treatments for whitening my teeth including: whitening toothpastes, whitening mouthwashes, other over-the-counter whitening gels, other In- office whitening treatments, or take-home whitening kits. By signing this, I have willingly elected to do my teeth whitening with Perfect Ten Smile.
COST
I understand that the cost of my Perfect Ten Smile teeth whitening treatment is determined by the current posted prices at the time of booking my appointment and that there are no additional costs or fees of any kind. I understand that only natural teeth will whiten and that any restorative material exposed to the whitening gel and light will not whiten because they are not as porous as natural teeth so they should not stain at the same rate as natural teeth. I understand that It may be necessary to have these materials replaced by my dentist to match the new tooth shade. I have taken into account this possibility and will bear the costs on my own.
RISKS OF CONSENT FOR TREATMENT
l also understand that the Perfect Ten Smile teeth whitening treatment results may vary or regress due to a variety of circumstances. I understand that almost all natural teeth can benefit from the Perfect Ten Smile teeth whitening treatment and significant whitening can be achieved in most cases. I understand that Perfect Ten Smile teeth whitening treatments are not intended to lighten artificial teeth, caps, crowns, veneers or porcelain composite or other restorative materials and that people with darkly stained yellow or yellow-brown teeth frequently achieve better results than people with gray or bluish-gray teeth. I understand that teeth with multiple colorations, bands, splotches or spots due to tetracycline use or fluorosis may have less dramatic whitening results. I understand that the Perfect Ten Smile teeth whitening treatment is not recommended for teeth with untreated cavities. As with any treatment, I should discuss my own dental heath situation with my dentist prior to using the Perfect Ten Smile teeth whitening treatment if I have any questions or concerns relating to my specific circumstance. I understand that the Perfect Ten Smile teeth whitening treatment is not recommended for pregnant or lactating women, or clients under the age of 16 years. I understand that the Perfect Ten Smile teeth whitening treatment cannot be undergone if I have an allergy to peroxides or glycols. I understand that the Perfect Ten Smile teeth whitening treatment is guaranteed to have immediate results to my satisfaction or the teeth whitening treatment is free.I understand that whitening treatments are considered generally safe by most dental professionals and are sold over-the-counter to individuals. I understand that although my Perfect Ten Smile teeth whitening professional has been trained in the proper use of the Perfect Ten Smile teeth 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- During the first 24 hours after the Perfect Ten Smile teeth whitening treatment some clients can experience some tooth sensitivity. Tooth sensitivity is a common side effect of peroxide-based tooth whitening. It is usually mild, but it can be worse in susceptible individuals. Normally, tooth sensitivity following the use of peroxide-based whitening products subsides within 24 hours.
People with existing sensitivity, recently cracked teeth, abfractions (micro-cracks), open cavities, leaking filings, or other dental conditions that cause sensitivity may find that those conditions increase or prolong tooth sensitivity.Gum Irritation - In rare cases, whitening gel may come in contact with the gum tissue during the treatment and may cause inflammation or whitening of my gums or gum line. This is due to inadvertent exposure of a small area of those tissues to the whitening gel and the inflammation and/or whitening is usually temporary and will subside almost immediately, with color change in the gum tissue reversing within 30 minutes.Dry Lips - The Perfect Ten Smile teeth whitening treatment involves up to a one hour session during which the mouth is kept open continuously for the entire treatment by a disposable cheek retractor or tray. 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.Relapse - After the Perfect Ten Smile teeth whitening treatment, it is natural for the teeth to regress somewhat in their shading over time. This is natural and should be very gradual, but it can be accelerated by exposing the teeth to various staining agents. I understand that the results of the treatment are not intended to be permanent and that repeat or touch-up treatments may be needed for me to maintain the tooth shade I desire for my teeth.In signing this informed consent I am stating I have read this informed consent (or it has been read to me) and I fully understand it and the possible risks, complications and benefits that can result from the Perfect Ten Smile teeth whitening treatment and that I agree to undergo the treatment as indicated on this form by my teeth whitening professional.