First Name

Last Name

Phone *

Email *

By checking this box, I consent to receive non-marketing text messages from LaBrows Beauty Studio about appointments, reminders and inquiries. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others, from LaBrows Beauty Studio at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

Date of Birth (You must be 18 or older) *

Davinci Teeth Whitening Consent

Please read and check each box below to confirm you understand.

Background and Procedure *

I understand that Davinci professional teeth whitening lightens the color of the teeth using a hydrogen peroxide mixture, designed for maximum whitening in the shortest time with minimum sensitivity. The whitening gel is applied in timed sessions per my package. A plastic cheek retractor keeps my mouth open, and a barrier covers my gums to isolate them from the gel. The shade of my teeth will be assessed and recorded before and after treatment.

Risk: Tooth Sensitivity *

I understand some clients experience tooth sensitivity during or after whitening. It is normal and generally mild. I will tell my technician before treatment if my teeth are normally sensitive, and during or after treatment if I feel discomfort.

Risk: Gum and Soft Tissue Irritation *

I understand whitening may cause inflammation of my gums, lips or cheek margins if the gel contacts these tissues. Protective materials are used to prevent this, but it can rarely still occur. Any irritation is generally short and very mild; rinsing with warm salt water can relieve it.

Risk: Existing Restorations *

I understand that white fillings, porcelain or composite restorations, crowns and veneers will not whiten during this procedure, and there may be color differences between my natural teeth and any veneers or crowns. I have discussed this with my technician before treatment.

Teeth Whitening: Expectations *

I understand significant whitening can be achieved in many cases, but there is no way to predict how light my teeth will get. Teeth with multiple colorations, bands, splotches or spots from tetracycline staining or fluorosis do not whiten as well and may appear more spotted for a short time after treatment. Teeth whitening is not recommended for pregnant or nursing women, anyone under 18, or anyone with a known peroxide allergy.

Teeth Whitening: Alternatives and Questions *

I understand there are other whitening options, such as take-home systems or teeth whitening paint, and I can ask my technician about them. If I did not understand anything explained to me during my consultation or in any printed material, I will ask.

Teeth Whitening: After-Treatment Care *

I understand that for 48 hours after treatment I must avoid consuming any staining (chromogenic) substances, such as tomato sauce, coffee and all tobacco products.

Teeth Whitening: Consent *

I understand my Davinci professional whitening results cannot be guaranteed. I have read this informed consent form and fully understand it and the possible risks, complications and benefits of the Davinci teeth whitening system.

Client Signature (I understand and agree to the conditions above) *

Clear