Babe with Blade, Inc.                                                    Teeth Whitening Consent & Release Form
By booking an appointment you acknowledge having read and agree to both the Booking Policy and Pre- Treatment Instructions.
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I understand that the amount of whitening cannot be predicted or guaranteed. Teeth will not whiten past your genetic whiteness (what you were born with). Yellow or brown teeth with surface stains whiten easier than grey or bluish teeth. Striped or spotted teeth are also difficult to whiten. Fillings, crowns or veneers will whiten back to the original color they were when first place. *
Required
Please check box that applies to you: *
I understand that White Teeth Whitening system uses hybrid (5% Hydrogen Peroxide and 20% Carbamide Peroxide) high intensity bleaching gels and high density cold blue light, which activates the gel’s components. This procedure may or may not require additional whitening in order to achieve your desired lightened shade. *
Required
I understand that White Teeth Whitening Gel has adjusted PH (acidity) and conditioners to reduce teeth and gum sensitivity, however, all teeth react differently. In the unlikelihood sensitivity occurs, it may be present for 1-2 days. Scientific articles have shown that the materials used in teeth whitening are safe and effective. It does not change the structure of teeth; it merely helps to achieve a whiter and brighter look. *
I understand that White Teeth Whitening Gel has conditioners and moisturizers in it to soothe the gums. If the gel comes in contact with, tingling and white bumps (blanching) can occur on gums; these are not harmful in any way and will disappear in 1-2 days. Everyone reacts differently to the whitening gel *
I understand that if you have fillings that are breaking down, decay in your teeth, erosion of the teeth, or exposed root surfaces due to periodontal disease, the gel will come in direct contact with these areas and may cause sensitivity during and after treatment. This sensitivity will go away within 1-2 days. *
Consent Form Acknowledgment
By signing the customer wavier and release agreement, I the client names below certify that I knowingly and voluntarily release Babe with a Blade, Inc. and Nicole DaCosta and it’s directors officers owners employees agents and representatives from any and all claims for damages for personal injury arising from the application and procedure of semi- permanent Lip Blush including damages relating known or unknown complications which may arise during or following the application process including but not limited to claims from negligence. I further release and hold harmless Babe with a Blade, Inc. and Nicole DaCosta from any claims related to preexisting conditions I have not revealed or changes to those conditions subsequent to the procedure.  I (client listed below) certify that I have read and fully understand this customer wavier and release agreement. I hereby authorize Babe with a Blade, Inc. and Nicole DaCosta to provide semi- permanent Lip Blush onto my own natural Lips and skin, in accordance with the terms and conditions set forth in this customer wavier and release agreement.
Name (by typing your full name you are acknowledging that this is an E-signature and that all information provided in true) *
Date of Service *
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Phone *
Client Medical History Form
Have you ever had a reaction in the past to: (check box if yes) *
Required
Are you (check box if yes)
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Do you have (check box if yes)
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When was your last dental cleaning (approx) *
Have you used whitening products in the past? *
Did you see any results? *
Did you have any negative side effects? (sensitive, chemical irritation, burnt tissues?) *
Name (by typing your full name you are acknowledging that this is an E-signature. You agree that all the information listed in the above "Client Medical History Form" is true and accurate to the best of your knowledge.
Date of Service
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