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Sparklediary.co.uk

CLIENT CONSENT AND CONSULTATION FORM
Are you 18 years of Age or More . . . . . . . . . . . . . . DO YOU HAVE ANY ALLERGIC RE-ACTIONS TO THE FOLLOWING? Latex . . . . . . . . . . . . . . . Nuts . . . . . . . . . . . . . . . . . . . . . . . . . Carbamide Peroxide. . . . . . . . . . . . . . . . . . . . DO YOU SUFFER FROM ANY OF THE FOLLOWING MEDICAL CONDITIONS? Asthma. . . . . . . . . . . . . . . . . . . . . . . . Skin Cancer. . . . . . . . . . . . . . . . . . . . . Seizure Disorder or Epilepsy. . . . . . . . Endocarditic (inflammation of the inner layer of the heart). . . . . . . . . . . . . . . . . . . Rheumatic Fever (an inflammatory disease). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Artificial Heart Valves. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Heart Condition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Are you Pregnant. . . . . . . . . . . . . . . . . . . . . Are you Breast feeding. . . . . . . . . . . . Had braces removed in the last two months……………………………………………………. If clients have an allergy to Nuts, then vitamin E swabs should be avoided and Vaseline should be applied to the gums instead. Although all steps have been taken to minimise any potential risks associated with the procedure, it is important to note and be aware that you may experience the following effects: - Soreness in gums and around the teeth - Peeling around the gums - Uneven whitening due to existing dental conditions - Coughing during the procedure and slight irritation to the throat Immediately following the treatment and for the first 48 hours, any drinks or food containing any food colour should be avoided. We recommend in taking only white foods for this period as the teeth will be susceptible to discolouration having used the stain removal which results in subsequent open pores of the teeth. These will take an approximate 48 hours to restructure and close. We would also suggest not to vigorously brushing the teeth and gums following treatment and electric tooth brushes should not be used for 48 hours due to any gum sensitivity
All the risks and responsibilities of the teeth whitening procedure have been explained to me in full.
I have filled in this form and understand the procedure. I understand that yellow or brownish teeth are easier to whiten and blur, grey, opaque are more difficult to whiten. I understand that damaged teeth from tetracycline are difficult to whiten and therefore cannot Be guaranteed the best 100% white results. I understand that my teeth, porcelain, caps, crowns, and veneers will only be whitened back to their Client Signature. . . . . . . . . . . . . . . . . . . . . . . . Clients Name. . . . . . . . . . . . . . . . . . . . . . . . . Technician Signature. . . . . . . . . . . . . . . . . . . . Technicians Name. . . . . . . . . . . . . . . . . . . . . . The Shade Information should be judged and entered onto this form at the start and end of each Top Teeth Start Shade. . . . . . . . . . . . End Shade. . . . . . . . . . . Shade Change. . . . . . . . . . . Bottom Teeth. . . . . . . . . . . . . . . . . . . . End Shade. . . . . . . . . . Shade Change. . . . . . . . . . . I declare that after having the treatment, the above details are correct. The Aftercare has been explained to me and I UNDERSTAND I SHOULD AVOID COLOURED FOOD AND DRINK AND SMOKING FOR THE NEXT 48 HOURS. Client signature……………………….

Source: http://sparklediary.co.uk/consent-form.pdf

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