Logo with a pink square border, the words 'Blissfully Browned' in pink cursive, and a small sun illustration beneath.

INFORMED CLIENT CONSENT FOR TEETH WHITENING TREATMENT

GENERAL INFORMATION

I acknowledge that I am purchasing a self-administered cosmetic teeth whitening service designed to improve the appearance and color of my natural teeth. As part of this service, I may receive professional guidance on the use of whitening materials and be provided access to a specially designed LED accelerator lamp to support the whitening process.

I understand that teeth whitening results vary from person to person. Teeth with yellow tones typically respond best. Teeth with discoloration caused by tetracycline use, fluorosis, or gray undertones may be more difficult to whiten. I acknowledge that artificial dental work — including crowns, veneers, caps, porcelain, composite fillings, or restorations — will not whiten and will not be damaged by the whitening gel.

I understand that my teeth will not become whiter than what my natural tooth structure allows.

SESSION LENGTH & CANDIDACY

I understand that teeth whitening sessions are offered in different time lengths based on individual preference and candidacy. Extended whitening sessions are recommended only for eligible clients and may be adjusted during treatment for comfort or safety. If a longer session is not recommended, I understand that my appointment time and pricing may be adjusted accordingly.

POTENTIAL RISKS & SIDE EFFECTS

Although cosmetic teeth whitening is generally considered safe, I understand that the following may occur:

Gum or Lip Irritation
Whitening gel that comes into contact with the gums or lips may cause temporary irritation or whitening of the soft tissue. This reaction is typically mild and resolves within approximately 30 minutes. A tingling or stinging sensation may occur if gel contacts soft tissue.

Tooth Sensitivity
Some clients may experience temporary tooth sensitivity during or within 24 hours following treatment. Sensitivity may be more noticeable in individuals with existing dental conditions such as cracked teeth, exposed roots, cavities, leaking fillings, or general tooth sensitivity. I understand that I should avoid extremely hot, cold, or spicy foods and beverages for at least 24 hours following treatment.

Spots or Streaks
White spots or streaks may appear temporarily due to naturally occurring calcium deposits in teeth. Whitening gel does not cause these spots but may make them temporarily more visible. These areas typically diminish over time.

Color Relapse
I understand that whitening results are not permanent and that tooth color may gradually regress. Exposure to staining substances such as coffee, tea, wine, soda, or tobacco may accelerate this process. I acknowledge that I should avoid all food and beverages except water for at least 60 minutes after treatment and that maintenance or touch-up treatments may be necessary.

ELIGIBILITY & MEDICAL DISCLOSURE

I understand that this treatment is not recommended for:

  • Pregnant or breastfeeding individuals

  • Individuals under the age of 16

  • Those with active gum disease, open cavities, leaking fillings, or untreated dental conditions

  • Individuals with known allergies to peroxide or aloe vera

I confirm that I am not currently taking photoreactive medications, or I have consulted my physician regarding the use of LED light during whitening treatments. These medications include, but are not limited to:
Chlorthiazide, Hydrochlorothiazide, Chlorthalidone, Naproxen, Oxaprozin, Nabumetone, Piroxicam, Doxycycline, Ciprofloxacin, Ofloxacin, Psoralens, Democlocycline, Norfloxacin, Sparfloxacin, Sulindac, Tetracycline, St. John’s Wort, Isotretinoin, and Tretinoin.

I understand that individuals who have recently had braces removed should wait until bonding residue has worn away before whitening. All oral piercings or metal objects must be removed prior to treatment, as discoloration may occur.

If I experience sharp or intense pain during treatment, I understand that I should stop immediately and consult a licensed dentist, as this may indicate an underlying dental issue.

ACKNOWLEDGEMENT & RELEASE OF LIABILITY

By signing below, I confirm that:

  • I have read and fully understand this consent form

  • I meet the eligibility requirements for treatment

  • I understand the risks, benefits, and limitations of cosmetic teeth whitening

  • I am voluntarily choosing to proceed under my own responsibility

  • I agree to release and hold harmless Blissfully Bronzed LLC, its owners, employees, and suppliers from any liability related to this cosmetic teeth whitening service

  • I certify that, to the best of my knowledge, I have healthy teeth and gums

ELECTRONIC SIGNATURE CONSENT

By typing my full name below, I understand that I am providing my electronic signature and that it carries the same legal effect as a handwritten signature.