Form

Informed consent for Whitening/Bleaching Treatment

authorize and give my consent for the dentist to perform the following procedure of whitening/bleaching my teeth.

1. The whitening procedure consists of wearing an appliance or mouthguard specially customized fitted for the patient's teeth and using a mild oxidizing agent whose active ingredient is Carbamide peroxide in a special glycerine base or the application of these same agents in the office by the dentist.

2. The techniques used in this bleaching treatment use similar agents which have been utilized in dentistry for a long time with no long-term detrimental effects upon the teeth or gingiva.

3. The amount of whitening is variable and unpredictable. A whitening of the teeth using the appliance or mouthguard will take place over a 2-3 week period when used as directed. Darker stains may require additional time to respond. Some patients may experience a relapse on discontinuance of the treatment, however, it is usually slight.

4. The patient may experience some of the following side effects during treatment:

Burning sensation of the gums or throat.
Sensitivity to hot and/or cold.
Soreness of the teeth.
Jaw Block.

5. Results of bleaching may include: areas of hypo calcification may appear whiter than adjacent tooth color (white spots will become whiter).

I have read and fully understand the above information, the attached instructions, and the procedure has been explained to me. I am further aware that individual teeth may bleach differently (cuspids may require additional bleaching).

First Name

Last Name

Date Of Birth

Patient Signature

Date

Witness Signature

Date

Doctor Signature

Date