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Guaranteed 5 to 14 Shades Whiter Teeth in ONE Visit!

White and Bright Best Teeth Whitening Studios

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Teeth whitening Client Information Form

First name*

Last name*

Email*

Phone

Address

Date of birth*

Day

Month

Year

Emergency Contact Name*

Phone

Dental History

Have you had teeth whitening before?*

Yes

If yes, please state when:

Do you have any crowns, bridges, veneers, or fillings?*

Yes

If yes, please state when:

Do you have sensitive teeth?*

Yes

When was your last dental visit?

Do you currently or have you had any of the following? Please check all that apply:*

Bleeding Gums

Dental Trauma

Genetic Disorder

Sores in Mouth

Tooth Discoloration

Untreated Dental Issues

None

Are you, or could you be pregnant/breastfeeding?*

Yes

Are you currently taking any medications?*

Yes

If yes, please list:

Do you have any other allergies?*

Yes

If yes, please list:

Life Style

Do you use any of the following? Please check all that apply:*

Coffee

Dark Sodas

Tea

Tobacco Products

Red Wine

None

Other

Guardian First Name and Last Name

Please complete this section only if the client is under 18 years old and you are their legal guardian.

Guardian date of birth

Day

Month

Year

By signing below, I agree to the following:

I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience to allow them to adjust accordingly. I agree to waive all liability toward my technician for any injury or damages incurred due to any misrepresentation.

Signature*

Signature field is empty.

Date*

Day

Month

Year