CLIENT: You have a right to be informed about this procedure, so that you may decide whether or not to undergo the procedure after knowing any risks 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 REVIEW THE FOLLOWING AFTERCARE INSTRUCTIONS prior to filling out the form below!

Lash Fantasy LED Teeth Whitening Aftercare Instructions

In the first 48 hours after your teeth whitening, the pores in your tooth enamel are open and can absorb stains faster than before.  As such, please observe the following recommendations:

Do not use any colored toothpastes, gels, colored mouthwash or home fluoride treatments.

If your daily homecare involves the use of Perio Rx or any Chlorahexidine, please wait 48 hours before continuing the usage of this product.

If post procedure sensitivity occurs, chew sugarless gum to reduce the peroxide levels, take an anti-inflammatory (Advil or Aleve) and brush with Sensodyne. Sometimes applying Sensodyne to your teeth for 5-10 minutes can relieve sensitivity.

Avoid extremely hot or cold liquids. These are dangerous to your white smile because they change the temperature of your teeth. This temperature change (hot and cold cycling) causes teeth to expand and contract, allowing stains to penetrate your teeth. Try cutting down on these types of drinks (including coffee and tea) or try drinking them with a straw to reduce the amount of time they are in contact with your teeth.

Avoid foods and drinks that are acidic. Acidic foods and beverages open up the pores of the tooth enamel allowing stains to more easily penetrate your teeth. Use a straw to help minimize the contact of these substances with your teeth. Once the pores close, which usually happens 24-48 hours after the procedure, you can resume your normal habits.

Cut back on drinking and smoking. Frequent consumption of alcoholic drinks and heavy smoking can reverse the effects of teeth whitening. Many alcoholic drinks such as wine have tannins that can stain the teeth. The same goes for the nicotine in tobacco.

Use smudge-proof lipstick to keep lipstick from getting on your teeth because regular lipstick can stain teeth.

Name (required)

Email (required)

Phone (required)

Address (required)

Date of Birth (required)

Are you under the age of 18? (required)
 Yes No

Are you pregnant or breastfeeding? (required)
 Yes No

Have you had oral surgery or extraction within the last 28 days? (required)
 Yes No

I understand that I will undergo Teeth Whitening treatment(s) using gel solution and an LED (Light Emitting Diode) device. (required)
 Yes No

I understand that multiple treatments may be necessary to achieve desired results. Treatments can take from 30 minutes up to one hour. 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. (required)
 Yes No

I understand that 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. Repeated teeth whitening may damage teeth. (required)
 Yes No

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. (required)
 Yes No

I am aware that I should be examined by a dentist prior to treatment. (required)
 Yes No

I understand that if I have veneers, porcelain, or other dental materials in my mouth, that these materials cannot get any whiter than their original color. (required)
 Yes No

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 worn teeth. I understand if I have any of these conditions I will advise my technician. (required)
 Yes No

If I am pregnant I understand that I may receive the LED Teeth Whitening service, however; I must first consult with my doctor. (required)
 Yes No

We will take before and after pictures of your teeth only (not your face). Do you give us permission to use your photos for advertising and marketing purposes? (required)
 Yes No

If you have any comments or questions, please enter here.

I have been provided a copy of, and understand, the Aftercare Instructions. I agree to follow these instructions carefully. I understand that compliance with recommended post procedure guidelines are crucial for 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. I release Lash Fantasy, staff, and specific technicians from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns. (required)
 Yes No

Aftercare Information: I understand that after treatment, I will be required to refrain from consuming any substances that could discolor my teeth for the first 48 hours after treatment. These substances include: coffee, tea, colas, ALL tobacco products, mustard or ketchup, red wine, curry, beetroot, soy sauce, berry pie, red sauces and lipstick. I understand that there are other substances that could discolor my teeth which I should avoid during the first 48 hours after treatment. (A good rule of thumb is that if it would stain a white shirt it could stain your teeth. If your teeth are sensitive, you can use Sensodyne Toothpaste for immediate relief. Of course, we suggest that you brush and floss as directed by your dentist. There is no guarantee as to the longevity of results.) (required)
 Yes No

By submitting this form, I agree to all terms on this form. Note: All prices are subject to change without prior notice.

 

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