General. I hereby acknowledge that I am having a BLEACHBRIGHT Tooth Whitening service done at Glitz Spray Tanning, which is designed to whiten the color of my teeth.
Results Guarantee. Although most natural teeth can benefit from tooth whitening treatments, I understand that everyone’s teeth are different and that results vary. I understand that people with yellowish teeth generally get the best results, and that if my teeth have grayish spots from tetracycline use, or flourosis, these will be difficult or even impossible to whiten. I further understand that if I have artificial teeth, caps, crowns, veneers, porcelain inlays, composite fillings, or other tooth colored restorative materials, I should not expect dramatic results from this treatment because the peroxide gel will not whiten (or damage) restorative dental materials. I am also aware that my teeth will never be whiter than is possible, which is determined by the nature of my fixed genetic tooth composition.
Potential Risks. Although Bleach Bright Tooth Whitening treatments are generally considered routine and safe there are rare cases of complications. I understand that some of the potential complications of this treatment may include, but are not limited to:
Gum or Lip Irritation. Whitening gel that comes in contact with gum tissue or the lips during the treatment may cause inflammation or whitening of these areas. This is due to inadvertent exposure of those tissues to the whitening gel. The inflammation and/or whitening of gum or lip soft tissue is transient, and the color change will reverse in 30 minutes to a few hours after treatment. You may feel a stinging and/or tingling sensation on these soft tissues during the treatment if the gel comes in contact with them. We will instruct you on how to apply the gel safely, and avoid your gum and lip soft tissues as much as possible.
Tooth Sensitivity. Although uncommon, you may experience some tooth sensitivity during the first 24 hours following your whitening treatments. If your teeth are already sensitive, or you have cracks, fissures, open cavities, leaking fillings or crowns, exposed roots or other dental conditions that cause tooth sensitivity, you may experience increased sensitivity during and/or prolonged sensitivity following your whitening treatments. Please inform your Technician if you experience any change in sensitivity during your whitening treatments
Spots or Streaks. You may develop white spots or streaks on your teeth due to calcium deposits that occur naturally in your teeth. The peroxide gel and/or the whitening process do NOT cause white spots or streaks. The whitening process has only made your existing calcium deposits visible again, and they will usually diminish over time. (24 Hours).
Relapse. After your treatments, it is natural for your teeth to regress in color over time. This is part of a natural aging process. The more you expose your teeth to various staining foods and beverages, such as coffee, tea, tobacco, red wine, cola, dark juices, the more you re-stain and darken your teeth. Just remember, anything you eat or drink, that would stain a white cotton shirt, will stain your teeth. We will provide you with After Care Instructions, and Dietary Suggestions that will help you keep your teeth whiter for longer.
We suggest that you consume only water for the first hour and avoid staining beverages for the first 24 hours.
By signing this agreement, you understand and consent to performing self-administered whitening treatments at Glitz Spray Tanning . You also confirm that you have read and understood this entire agreement, including the potential risks, complications, and side effects, versus the benefits of whitening treatments. You also understand the need for follow-up care and proper maintenance in order to maintain a lighter tooth color shade over time. I understand that I am performing this treatment under my own responsibility and care, and that I must follow all instructions during the process. I certify to the best of my knowledge, that my teeth and gums are healthy and that I am eligible for treatment and hold no responsibility to the Technician at Glitz Spray Tanning.
