Teeth Whitening Agreement Form Name * First Name Last Name Do you knowingly and willingly consent to receiving facials and body treatments, teeth whitening, brow tinting, and/or any other beauty service we offer during the Covid-19 pandemic? * Yes No Do you agree to follow NJ law that requires everyone to wear a mask and follow social distancing guidelines? * Yes No I understand the following candidates are to be excluded from a whitening session: Allergies or reactions to either carbamide or hydrogen peroxide, have tooth decay or periodontal disease, pregnant or suspected to be pregnant or breastfeeding, under the age of 18, or have oral surgery or extractions within 28 days * Yes No I understand that I will not experience any heat or discomfort, however in some cases, I may feel a tingling sensation or perhaps a slight sensitivity. * Yes No I understand that existing issues should be treated before undergoing a whitening procedure. * Yes No I understand that results cannot be guaranteed. * Yes No I understand that teeth whitening treatments are not intended to lighten artificial teeth, caps, crowns, veneers, or porcelain, composite or other restorative materials. If there are stains on cosmetic caps, crown or filing, it can be lifted, however the original color cannot be altered. * Yes No I understand that darkly stained, yellow or yellow-brown teeth frequently achieve better results than people with gray or blueish-gray teeth. * Yes No I understand teeth with multiple coloration’s, bands, or splotches or spots due to fluorosis do not whiten as well, may whiten unevenly, may require additional whitening, or may not whiten at all. * Yes No I understand that whitening may cause inflammation of the gums, lips, and/or cheek margins. I may see a white film on my gums after the procedure which is normal and temporary due to the solution. * Yes No I understand during the first 24 hours after the treatment, I can experience some tooth sensitivity or discomfort. * Yes No AFTERCARE: I understand that for a minimum of 24 hours, I should avoid eating or drinking any chromogenic substances that would stain my teeth. A good rule of thumb is; if it can stain a white shirt, it can stain your teeth. * (i.e: tomato sauce, coffee, red wine and all tobacco substances) Yes No Do you agree to allow GLO Aesthetics to take photos and videos of you and give them permission to use them for any legal use including but not limited to marketing and social media? * GLO Aesthetics will never use your image in a negative way! I agree Today's Date: * MM DD YYYY Digital Signature * Please type your full name below. By typing and submitting this form, this serves as a Digital Signature and verifies that you fully agree to our policies for our services. Signing this document confirms that you understand and agree to all terms and statements on this form. This digital signature holds the same authority as a handwritten one. Signing and agreeing to this form makes this form valid for all future appointments and services you receive by GLO Aesthetics. Thank you! Thank you!
