Enhanced Whitening Patient Consent

GENERAL DESCRIPTION
The amount of whitening varies from patient to patient and cannot be predicted or guaranteed. But in general:
1. Yellow or brown teeth, surface stains, and uniformly darkened teeth are easier to whiten than grey or bluish teeth. Striped or spotted teeth are difficult to whiten.
2. This Whitening System uses an effective whitening procedure that may or may not require additional whitening treatments and home care in order to reach a desired lightened shade. Additional procedures or treatments could include take-home products or additional office visits, which may be an additional expense to the patient.

CANDIDATES FOR TREATMENT
Most people are potential candidates for the whitening procedure. However, there are a few exceptions:
1. People with significant periodontal/gum disease are not candidates.
2. People with fillings that may be breaking down, unfilled cavities in their teeth, or chipped/worn teeth may be better treated by restorative procedures first.
3. Not suitable for pregnant or breastfeeding women.
4. People with minimal discoloration (teeth that are already white) may not see a substantial colour change.

RISKS
1. Scientific articles have shown that the materials used by us to whiten your teeth are effective and safe. It does not change the structure of teeth; it merely makes them appear whiter and brighter.
2. If tooth sensitivity develops, desensitising paste, such as colgate sensitive pro relief toothpaste or sensodyne may be recommended for reducing sensitivity. If sensitivity persists for more than 12 hours or is severe, contact us.
3. The whitening procedure can cause temporary inflammation and white spots on your gums. In the event this happens we will immediately apply VITAMIN E oil. This should resolve very quickly.
4. If you have tooth sensitivity, fillings that are breaking down, decay in your teeth, erosion of the teeth, or exposed root surfaces due to periodontal disease, the peroxide may have direct access to the affected areas. These conditions need correction prior to the whitening procedure.
5. The whitening procedure can be very effective at whitening the teeth, but will not change the colour of fillings or crown(s) already in your teeth. For aesthetic reasons, such fillings may need changing after the whitening procedures.
6. The whitening treatment plan has been reported not to be effective on some patients. We will provide our best efforts to whiten your teeth but lightening results cannot be guaranteed.

RESPONSIBILITIES
1. Avoid the use of tobacco and teeth-staining foods and beverages such as: tea, coffee, red wine, tomato paste, curries, dark fruits/vegetables for 2 days after the whitening procedure.
2. Never place household or commercial bleaches in your mouth.
3. If you have any questions or concerns, contact Alice at alice@restorehygiene.com.au

GUARANTEES
There are no guarantees as to the degree of whitening of your teeth.
1. The amount of whitening varies with the individual.
2. Additional whitening sessions and the use of ancillary whitening systems may be required to obtain desired results, and may incur an extra fee.
3. In some instances the lightening effect is minimal or unapparent and will need subsequent treatments over a longer period to be effective.

CONSENT
1. I consent to photographs being taken. I understand they may be used for record documentation and for illustration of my treatment.
2. The risks, responsibilities, and benefits have been explained to me and I understand them.
3. I understand that the cost of my Professional Whitening Treatment is determined by my dental professional.
4. I have had the opportunity to ask questions and my questions have been answered.
5. I have read the above information, I consent to treatment, and I assume the responsibility for the risks described above.