IN-OFFICE
TEETH WHITENING CONSENT FORM

_In-Office whitening treatment results may vary due to a variety of circumstances. I understand that almost all natural teeth can be lightened from In-Office Whitening treatment. I understand that In-Office Whitening treatments are not intended to lighten artificial teeth, caps, crowns, veneers or porcelain, composite or other restorative materials.

_Tooth sensitivity and/or gum irritation may occur and is normal and is usually mild, but it can be worse in susceptible individuals. Usually, tooth sensitivity and/or gum irritation following a whitening treatment subsides after a few days. People with existing sensitivity, exposed dentin, exposed root surfaces, worn teeth, damaged or missing enamel, cracked teeth, cavities or leaking fillings allow penetration of the gel into the tooth may find that those conditions increase or prolong tooth sensitivity and/or gum irritation after treatment.

_Results of the whitening treatment is not intended to permanent. I will be required to refrain from consuming any substances that could discolor my teeth for 48 hours.

_Staff of Teeth By Tianna are Certified Teeth Whitening Specialist not dentist. We encourage everyone to keep up good oral hygiene. Consult with your dental provider for oral care.

_Teeth By Tianna own the exclusive rights to display photos and/or videos taken and use of promotion. 

By completing this form I agree to terms & conditions.