Consent Teeth Whitening | The Aesthetic Chapter Singapore

Name *

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About The Procedure

To the CLIENT: You have a right to be informed about your condition and its treatment, so that you may decide whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give, or withhold, your consent for treatment.

Please read the following statements carefully *

I understand that I will undergo Teeth Whitening treatment(s) using gel solution and a LED (Light Emitting Diode) device.
I understand thulat multiple treatments may be necessary to achieve desired rests. Treatments can take from 30 minutes. Additional treatments may be necessary to maintain desired results. No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. Results will vary per patient. I agree to adhere to all safety precautions and regulations during the treatment.
Possible Side Effects can include but are not limited to: Allergic reaction to the gel solution, tooth sensitivity and irritation of the soft tissues (particularly the gums). In rare cases the use of LED’s can damage the pulp (soft tissue in the center of teeth) of teeth.
I understand that if I am not being treated by a dentist, my technician has no dental qualifications and that my teeth are not being examined for health, cavities, etc.
I understand that if I have veneers, porcelain, or other dental materials in my mouth, that these materials can not get any whiter than their original color.
I understand I am not a good candidate for this procedure if I have significant periodontal disease, fillings that may be breaking down, unfilled cavities, or chipped or warn teeth. I understand if I have any of these conditions I will advise my technician
If I am pregnant I understand that I may receive the LED Teeth Whitening service, however; I must first consult with my doctor.

Acknowledgement

I have read and understand the Pre and Post-Treatment Instructions. I agree to follow these instructions carefully. I understand that compliance with recommended pre and post procedure guidelines are crucial for healing, prevention of side effects and complications as listed above. The nature and purpose of the treatment have been explained to me. I have read and understand this agreement. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement.

Consent For Japan LED Teeth Whitening