Tooth Whitening Consent & Waiver Form

If you’ve reached this page, you’re just about to LEVEL UP with some designer smile badassery! Please fill out the following form to the best of your ability including your signature at the bottom.

As always, if you have any questions, please do not hesitate to ask me before we get started with the procedure!

CONTACT INFO:

Your First and Last Name

Your Email

PROCEDURE VERIFICATION
Do you confirm that the tooth or teeth being whitened today are free of cracks, chips, or damage and does not require dental work to your knowledge?
YesNo
I understand that tooth whitening is not as effective for crowns, fillings, or veneers. In fact, I may see no results on dental work like these at all.
YesNo
I understand that tooth whitening is not a permanent fix and that it may require touch up appointments to maintain a lighter color for my teeth.
YesNo
I understand that I should abstain from eating or drinking any deeply pigmented or stain-causing foods, drinks, or habits for 48 hours following the whitening procedure.
[checkbox* 48HrsNoStainFood use_label_element "Yes" "No"]
I understand that my results will be maximized if I use tooth whitening maintenance products and maintain regular visits to my dental hygienist.
[checkbox* 48HrsNoStainFood use_label_element "Yes" "No"]
I understand that there are no exchanges or refunds for cosmetic dental services provided.
YesNo

CONSENT, RELEASE OF LIABILITY, & CLAIM WAIVER
Please the following consideration of receiving a tooth gem, gold gem, or similar tooth gem product from the Tooth Gem Technician, Avani Joy Visone, and the use of facilities provided by Root & Crown (Raging Roots Studio LLC) and its employees, you agree to the following:
1. I certify that this informed consent and waiver form was completed by me the aforementioned, and I confirm that I understand all the questions, terms, and conditions, entries in it and the information herein is complete to the best of my knowledge. I agree to observe and obey all posted, written, and oral rules and warnings, including on those materials provided by Root & Crown.
2. I agree to waive and release to the fullest extent permitted by applicable state law of the tooth gem technician, all employees, contractors, and the management of the studio where services are being rendered from all liability whatsoever, for any and all claims or causes of action that, my estate, heirs, executors, or assigns may have for personal injury or otherwise, including any direct or consequential damages, which result or arise from the tooth whitening agent whether caused by negligence or fault of the tooth whitening technician.
3. I am 16 years or older.
4. I understand that the application of tooth gems and associated products does not include any drilling into the tooth or breaking the skin and may cause marks or discoloration of my teeth especially if I do not maintain proper dental hygiene following placement of tooth gems.
5. I understand that tooth whitening can, in many cases, restore your teeth to a youthful dolor. The procedure does not harm your teeth and may take two weeks to complete. As in all esthetic enhancement procedures, there are variables and end results are not guaranteed. In most cases, teeth will become several shades brighter. The type of discoloration affecting the teeth, my dietary habits, maintenance, and overall condition of my teeth may affect the outcome of the treatment and the term of the results.
6. I understand that additional charges may be incurred for special situations where treatment time is extrended.
7. I understand that during the entire treatment a retractor will be placed in my mouth to help keep it open and protect the soft tissues of the mouth (lips, gums, cheeks, and tongue) will be covered to ensure they are not exposed to the tooth whitening gel.
8. I understand that in-office whitening treatments are not intended to lighten artificial teeth, caps, crowns, veneers, porcelain, composite, or other restorative dental materials that may or may not have existing stains.
9. I understand that teeth with multiple colorations, bands, blotches, or spots due to tetracycline use or fluorosis do not whiten as well and may need multiple treatment or may not whiten at all.
10. I understand that to achieve desired results, I may require 2 - 3 sessions of in-office whitening, a follow-up treatment is also recommend 2 - 6 weeks following first in-office treatment.
11. I am aware of the basic procedures of whitening treatments and the advantages, risks and known possible complications or alternative treatments as they have been explained to me by my technician who has answered all my questions.
12. I understand that potential side effects include:
a. Tooth sensitivity which may occur during whitening. This is a temporary side effect and usually resolves itself. It may be relieved by a mild analgesic such as Advil, Tylenol, or Fluoride treatments in conjunction with whitening.
b. Leaky, faulty restorations or cavities must be treated before beginning or continuing with the procedure.
c. Exposed root surfaces, grooves, notches, or depressions where the teeth meet the gums will be isolated from whitening gel, yet may be sensitive during and/or shortly following treatment.
d. Dental restorations such as bridges, crowns, veneers, and fillings will not lighten with the tooth whitening and may need partial or complete replacement to reach my whitening goals.
e. Since it is impossible to state every complication that may occur as a results of whitening treatments, the list of complications in this form is incomplete. The basic procedures of whitening treatments and the advantages and disadvantages; risks and known possible complications of alternative treatments have been explained to me by my dentist/hygienist and my dentist/hygienist has answered all my questions to my satisfaction.
13. In signing this informed consent, I am stating that I have had 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 whitening treatment and that I agree to undergo the treatment as described to my dentist and/or their staff.
14. I hereby authorize Avani Joy Visone, my tooth gem technician, and the studio permission to take photos and use my likeness in photography or video for its promotional materials and publications, print and digital. I understand and agree that all rights to any photos of me belong to Root & Crown (Raging Roots Studio LLC).
15. The invalidity or unenforceability of any provision or this Release of Liability shall not have any effect of any other provision of this Release of Liability or of any other applications of such provision, and such unenforceable provision shall be deemed not to be a part of this Release of Liability.
16. The parties will attempt to resolve any dispute arising out of or relating to this Release of Liability through friendly negotiations. If the matter is not resolved, the parties agree to use mediation.
I understand that there are NO exchanges or refunds for services provided.
I HAVE READ THIS DOCUMENT AND UNDERSTAND ITS CONTENTS. I FURTHER UNDERSATND THAT BY SIGNING THIS RELEASE OF LIABILITY, I VOLUNTARILY SURRENDER CERTAIN RIGHTS. ROOT & CROWN (RAGING ROOTS STUDIO LLC) IS NOT RESPONSIBLE FOR ANY DAMAGE CAUSED BY TOOTH GEM APPLICATION.
First & Last Name

Date of Service

Please Sign Below: