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Teeth Whitening Client Information Form

Date of birth
Day
Month
Year

Dental History 

Have you had teeth whitening before?
Yes
No
If yes, please state when:
Do you have any Crowns, Bridges, Veneers, or Composite bonding?
Yes
No
If yes, please state if they are on your front or back teeth
Do you have sensitive teeth?
Yes
No
Do you currently or have you had any of the following? Please check all that apply:
Are you currently taking any medications?
Yes
No
If yes, please list:
Do you have any other allergies?
Yes
No
If yes, please list:

Life Style

Do you regularly consume any of the following? (Please tick all that apply)

Please complete this section only if the client is under 18 years old and you are their legal guardian.

Guardian date of birth
Day
Month
Year

By signing below, I agree to the following: 

I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience to allow them to adjust accordingly. I agree to waive all liability toward my technician for any injury or damages incurred due to any misrepresentation.

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Date
Day
Month
Year

Photography consent & release form

Note: We will capture photos of your teeth before and after treatment for comparison.

Date of birth
Day
Month
Year
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Photo & Video Release Form

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