MOD Mouth Brilliant Teeth Whitening Consent Form

The MOD Brilliant Teeth Whitening system includes the MOD Mouth in store "Stain Exfoliation and Brightening" treatment along with our exclusive at home MOD Mouth whitening kit. The procedure is quick, painless and offers the ability to safely whiten and brighten your smile and provides the tools needed to continue brightening as a part of your regular oral care and beauty regimen.

After brushing your teeth at our Brushing station a 20% Hydrogen Peroxide stain exfoliation strip is placed around your smile teeth and professionally molded to your teeth with special detail to remove both surface stains as well as stains between your teeth. This strip is removed either at home or in the store after 30 minutes of wear. You will, additionally be given MOD Mouth at home whitening rinse and serum to continue the whitening experience and bring the power of your smile.

Risks: Complications that can occur in professional teeth whitening are infrequent and are usually minor in nature.
Tooth Sensitivity: Though our whitening system has been shown to have minimal to no sensitivity, during and after the whitening process some may experience tooth sensitivity. This is normal and generally mild if your teeth are not normally sensitive. If your teeth are normally very sensitive, please inform us before treatment. Please let us know if you experience any discomfort during or after the procedure so we are able to minimize your discomfort.
Gum and soft tissue irritation: Whitening may cause inflammation of your gums, lips or cheek margins. This is generally the result of the whitening gel coming into contact with these tissues. This irritation will typically reside within an hour.
Existing restorations: White fillings; porcelain or composite restorations, crowns or veneers will not whiten at all during this procedure.

Treatment Responsibilities: If you do not understand something communicated to you during consultation, or in any printed material given to you before or after the procedure, please feel free to ask.

Expectations: Significant whitening can be achieved in many cases, but there is no absolute way to predict how light your teeth will get. Please understand that teeth with multiple colorations, bands, splotches or spots due to tetracycline staining or fluorosis do not whiten as well and may appear more spotted after treatment. These effects are generally short in duration. Teeth whitening is not recommended for pregnant or lactating women, children under 16 years of age or any persons having known peroxides allergies.

Informed consent & agreement

I hereby state that my dentist or hygienist cleaned my teeth within 6 months from starting MOD Mouth Brilliant Whitening. My dentist took x-rays of my teeth. My dentist checked for and repaired all known or diagnosed cavities, loose or defective fillings, crowns or bridges. My dentist has probed or measured my gum pockets and says I do not have periodontal or gum disease. I have no pain in any of my teeth. I have no pain in my jaws. I have no loose teeth.

I have read and understand the content of this document describing considerations and risks of MOD Mouth Brilliant Whitening. I have been sufficiently informed and have been given the opportunity to discuss this form and its contents with the MOD Mouth dentist, and to have my questions adequately answered. I have been asked to make a choice about my treatment, and I hereby consent to receive treatment with 20% Hydrogen Peroxide in office whitening strips and at home rinse and whitening serum manufactured by MOD Mouth following the MOD Mouth protocol.

I acknowledge that neither my doctor nor MOD Mouth, its employees, representatives, successors, assigns, or agents, have, can, or will make any promises or guarantees as to the success of my treatment or give any assurances of any kind concerning any particular result of my treatment.

I understand that MOD Mouth may transfer my health and dental records, diagnosis, consultation, treatment, of medical/dental information, both orally and visually, to an affiliated MOD Mouth team member.

I certify that I can read and understand English. I have read this form and fully understand the benefits and risks listed in this form related to my use of MOD Mouth Brilliant teeth whitening. I have had an opportunity to discuss and ask any questions to a MOD Mouth provider about the use of MOD Mouth Brilliant teeth whitening.

I understand that after treatment, I should refrain from consuming any chromogenic substances (i.e. tomato sauce, coffee, Colored drinks and all tobacco products) for 48 hours.

In signing this informed consent I am stating I have read this informed consent and I fully understand it and the possible risks, complications and benefits that can result from the MOD Mouth Brilliant teeth whitening.

 

Patient's Signature:

Clear

Date:

Guardian/Parent Signature:

Clear

Date: