Microsoft word - teeth whitening.doc

Confidential Patient Case History – Beyond Whitening
Name _____________________________________ Date ___________ DOB ____________
Address ______________________________________________________________________
City ______________________________ State _____________ Zip Code _____________
Home Phone ____________ Work ____________ Mobile ___________ Other ___________
How did you hear of us? Dallas Voice Internet Observer Radio Passport Other _____________
Email: _______________________________________________________________________________
General Medical History
Accutane

Medical Problems we should know of? _______________________________________________________________
Are you currently pregnant or trying to get pregnant ? __________________________________________________

Taking any types of drugs including any mood altering drugs? Tetracycline

(others please list) _________________________________________________________________________________
Have you tried whitening your teeth in the past?________________________________________________________
If yes, what product did you use?__________________________________________________________________
Patient Consent for Beyond White Tooth Whitening
Patient Name: _________________________________________________________
Procedure: Tooth Whitening
Device: Beyond White lamp with hydrogen peroxide gel
I hereby authorize and direct any associates or assistants of Advanced Skin Fitness to perform Beyond White Tooth
Whitening on me. Multiple treatments may be required to achieve cosmetically acceptable results. In rare cases,
patients may not experience any improvement in the coloration of their teeth even with multiple treatments. I specifically
acknowledge that no guarantees or warranties have been made concerning the results of the procedure.
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 cosmetologist has been trained in the proper use of the Beyond
White System, the treatment is not without risk.
I understand that some of the potential complications of this treatment include, but are not limited to the
following: (please initial each statement)


_____ During the first 24 hours after the Beyond White treatment, some clients can experience some tooth sensitivity.
While uncommon with the Beyond White system, tooth sensitivity is a common side effect of peroxide-based tooth
whitening. It is usually mild, but it can be worse in some 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 fillings or other dental conditions that cause sensitivity may find that
those conditions increase or prolong tooth sensitivity after the Beyond White treatment.
_____ The Beyond White treatment involves three, 20-minute sessions during which the mouth is kept open for the
entire treatment by a plastic retractor. 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 cream.
_____ After the Beyond White 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 therefore, repeat or touch-up
treatments may be needed for me to maintain the tooth shade I desire for my teeth.
_____ I understand that for 24 hours after the Beyond White treatment eating or drinking dark staining substances such
as: coffee, tea, red wine, soy sauce or cola, smoking cigarettes or using colored toothpaste will lessen the effectiveness of
my treatment and has a possibility of permanently staining my teeth.
ACKNOWLEDGEMENT
I understand that I release Advanced Skin Fitness and its associates, the Medical Director, the technician performing services, and any other person involved in my treatment from any liability associated with complications from the Beyond White procedure. I am aware that Advanced Skin Fitness has a 24 hour cancellation policy. Similarly, I will be charged $100 for any broken appointment without 24 hour cancellation. I understand that all procedures are priced per treatment. I understand that no guarantees can be made and all payments are non-refundable. By my signature below, I certify that I have read and fully understand the contents of this permission and authorize the performance Beyond White Tooth Whitening by the staff of Advanced Skin Fitness. Patient or legal guardian signature and date _____________________________________________________________ Witness signature and date __________________________________________________________________________
Pre-treatment shades:

Upper

Lower teeth:___________________
Post treatment shades:

Upper
Client signature:_______________________________________Date:_______________ Witness:_____________________________________________Date:_______________ Credit Card Charge Authorization Agreement We request the courtesy of a 24 hour notice in the event an appointment needs to be cancelled or rescheduled. A $75 no show fee for facial treatments and a $100 no show fee for laser treatments will apply in the event advanced cancellation notice is not given. Appointments booked same day of service will be assessed a no show fee should cancellation become necessary. For treatments that are pre-paid, the pre-paid treatment will be forfeited without 24 hour notice of cancellation. Thank you for your cooperation. I, _____________________________________________________________, hereby authorize Advanced Skin Fitness to charge my credit card used for my treatments in the amount of $75 for a missed facial treatment or $100 for a missed laser treatment. I have read this entire agreement and understand that I will be held fully responsible for its terms and charges. I agree not to chargeback Advanced Skin Fitness, as long as I receive the services that are entitled to me and guidelines are followed for my rescheduling and cancellation of appointments. Twenty-four hour notice is required for all rescheduling and cancellations. Name On Card: ___________________________________________________ Signature: _______________________________________________________ Credit Card Billing Address: _________________________________________ City, State, Zip: ___________________________________________________ Telephone: (_____) ______________ Date: ____/____/____

Source: http://advancedskinfitness.com/wp-content/uploads/ASF-Teeth-Whitening.pdf