Consent

Informational Consent Form

General Information

This information has been given to me so that I can make an informed decision about having my teeth whitened. I understand that I can take as much time as needed to decide whether the whitening process is right for me. I understand that I can ask questions about the procedure and should not have the procedure performed unless all my questions are answered with language and an explanation that I truly and fully understand.

Tooth whitening is designed to lighten the color of your teeth. Significant whitening can be achieved in the vast majority of patients but the RESULTS CANNOT BE GUARANTEED. When done properly, the Sm;)e Perfected™ whitening system will not harm your teeth or gums. However, like any other dental treatment, it has some inherent risk and limitations. These are seldom serious enough to discourage you from having your teeth whitened, but should be considered when deciding to have the treatment.

The active ingredient in teeth whitening is carbemide peroxide in a glycerin base. If you know of any allergy or adverse reaction to either ingredient please do not proceed with the procedure.

THE AMOUNT OF WHITENESS VARIES WITH EACH INDIVIDUAL!

Sm;)e Perfected™ IS A CONTIUOUS MAINTENANCE WHITENING PROGRAM

Candidates for Tooth Whitening

Almost anyone is a candidate for Sm;)e Perfected™ Tooth Whitening. However, people with dark yellow or yellow-brown teeth tend to whiten better than people with gray or bluish-gray teeth. In addition, multi-colored teeth, especially if due to tetracycline, do not whiten very well. Any current restoration(s) you have such as fillings, porcelain crowns, porcelain veneers, onlays and inlays cannot be whitened.

Women who are pregnant or nursing should not have the Sm;)e Perfected™ procedure done.

Patients under the age of 14 should not have the Sm;)e Perfected™ procedure done.

Patients with active decay or gum disease should not have the Sm;)e Perfected™ procedure done.

Sm;)e Perfected™

Sm;)e Perfected™ is an in-office maintenance whitening procedure. There is no prep time and takes about 20 minutes from start to finish. You will/can leave with your medical grade silicone tray. You are encouraged to use the Sm;)e Perfected™ whitening pen in conjunction with your silicone tray.

Potential Problems

SESITIVITY:

Tooth Sensitivity rarely occurs with Sm;)e Perfected™. If it does, it is usually mild and will discontinue after the whitening gel is removed. Patients with root sensitivity are more susceptible to sensitivity from whitening. If your teeth continue to be sensitive after the whitening procedure, a mild analgesic such as Tylenol or Advil will usually be effective in making you more comfortable until the sensitive subsides.

GUM IRRITATION:

Sm;)e Perfected™ is formulated at a concentration level that should not cause an irritation to healthy gums. Some patient’s gum tissue is more sensitive to the whitening gel than other patients and will, on occasion, experience a localized temporary inflammation and white spot(s). A burning sensation on the gums might also occur but is very rare. G-U-M Rincinol P.R.N. Oral Pain Reliever helps heal and soothe irritated tissue.

LIP IRRITATION:

Please use copious amounts of the Vitamin E Swab to protect your lips from the light and whitening gel during the procedure. If irritated, a mild analgesic such as Tylenol or Advil will usually be effective in making you more comfortable until the irritation subsides. You may also apply lip balm, petroleum jelly, or Vitamin E Cream after the procedure.

ROOT RESORPTION:

This is a condition where the root of the tooth starts to dissolve either from the inside out or outside in. The cause is unknown. There has been some evidence to suggest that patients who have undergone root canal therapy are at a higher risk for this to occur following the whitening procedure.

After the Procedure and Possible Relapse

For the first 24 hours your teeth are susceptible to staining from environmental challenges such as soft drinks, coffee, tea, wine, and certain foods like spaghetti sauce. As a general rule, anything that would stain your clothes should not be consumed for the first 24 hours following your whitening procedure. You will/can leave with your medical grade silicone tray. You are encouraged to use the Sm;)e Perfected™ whitening pen in conjunction with your silicone tray to maintain your whitening procedure.

By providing my signature, I certify that I have read (or it has been read to me) and understand the above information concerning Sm;)e Perfected™ whitening. I have been informed of the treatment, the fees, any alternatives, and the benefits and risk involved. All of my questions have been answered to my satisfaction.

I also understand that other dental procedures might have been recommended for the health of my mouth. I understand the risks of ignoring these professional recommendations and take full responsibility for any further tooth decay or periodontal disease (gum disease) in my mouth.

No guarantee or assurance has been given to me by anyone with respect to the final outcome since the procedure is not predictable because of clinical differences from patient to patient.

I consent to the Sm;)e Perfected™ Whitening procedure.

Patient/Guardian Signature:

Patient Name Printed:

Parent/Guardian Name Printed:

Witness:

Date:

(If the patient is a minor then the parent or guardian will consent on behalf of the minor patient for the Sm;)e Perfected™ whitening procedure)