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Consent Form

Please complete this consent form before your Cosmetic Teeth Whitening appointment. Once you sign, a copy is emailed to you and to Gemma automatically.

Your details

Cosmetic Teeth Whitening — treatment information & disclaimer

Cosmetic teeth whitening lightens the colour of the teeth using a whitening gel. Results vary depending on the starting colour and condition of your teeth, and existing fillings, crowns or veneers will not change colour, which may lead to an uneven result. There are no guarantees of a specific shade.

Possible side effects include temporary tooth sensitivity and gum irritation, which usually settle after treatment. Overuse of whitening products can affect the enamel or gums. You confirm you are not allergic to any of the ingredients in the whitening gel and will follow all aftercare instructions.

A non-refundable deposit is required to secure your appointment. The balance is payable at your appointment. Deposits and booking fees are non-refundable unless agreed with the practitioner.

Medical screening

Please answer honestly — this keeps your treatment safe. Add detail in the notes where relevant.

1. Are you pregnant, breastfeeding, or trying to get pregnant?
2. Do you have any medical conditions? If yes, please give details.
3. Are you taking any medication (including blood thinners such as Warfarin/Aspirin)? If yes, please list.
4. Do you have any allergies, or have you ever had anaphylaxis? If yes, please give details.
5. Do you have any skin or neuromuscular disorders?
6. Do you have diabetes, an autoimmune disease, or a bleeding/clotting disorder?
7. Do you have a history of keloid or hypertrophic (raised) scarring?
8. Do you have any active infection, cold sores, or inflammation at the treatment area?
9. Have you had this or a similar treatment before? If so, did you have any problems?
10. What are your aims and motivations for the treatment / desired outcome? Please give details.
11. Is there any other medical or social history we should know? Please give full details.
12. Do you understand the information provided and feel it is sufficient for you to consent?
13. Has your consent been given freely?

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