Professional Chairside Whitening

Introduction

The following information has been given to me so that I can make an informed decision regarding the use of the Professional Chairside Whitening treatment. I may take as much time as needed to make my decision about signing this informed consent form. I have the right to ask questions about any procedure before agreeing to undergo the procedure. My dentist has informed me that there is a level of discoloration present on my teeth; this discoloration could be treated via in-office whitening, take home whitening or both. These procedures are informally referred to as “bleaching”.

Description Of The Procedure:

The following information has been given to me so that I can make an informed decision regarding the use of the Professional Chairside Whitening treatment. I may take as much time as needed to make my decision about signing this informed consent form. I have the right to ask questions about any procedure before agreeing to undergo the procedure. My dentist has informed me that there is a level of discoloration present on my teeth; this discoloration could be treated via in-office whitening, take home whitening or both. These procedures are informally referred to as “bleaching”.

Alternative Treatments

I understand that I have the ability to forego Chairside Whitening. However, should I choose not to proceed with Chairside treatment, I understand there are alternative whitening treatments for which my dentist can provide additional information. These treatments include:

• Professional Take Home Whitening Kits
• Whitening Toothpaste/Gels
• Other in-office whitening systems

Cost

I understand that my dentist determines the cost of the Chairside procedure.

Risks Of Treatment

I understand that Chairside results may vary due to a variety of circumstances, and that the variability of these circumstances and results makes it virtually impossible to guarantee the results of any whitening system.

I understand that Chairside whitening is not recommended for certain patients, including:

• Patients under 13 years of age
• Patients with braces.
• Pregnant or lactating women.

I understand that the vast majority of the dental professional community considers in-office whitening treatments as generally safe procedures, and that my dentist has been trained in the proper use of the system; however, I am aware that the treatment is not without risk. I understand that potential complications include, but are not limited to:

Tooth Sensitivity/Pain – Although the Chairside System is designed to eliminate or reduce any sensitivity, a minimal number of patients may experience some discomfort within the first 24 hours of treatment. The vast majority of patients who experience discomfort consider it to be mild, but the discomfort will vary between individuals. This sensitivity will generally subside within 24 to 36 hours, but may last longer for a small number of patients. Patients with pre-existing sensitivity, recession, exposed dentin, exposed root surfaces, and occlusal wear facets (severely worn teeth), damaged or missing enamel, cracked teeth, abfractions (micro-cracks), open cavities, leaking fillings, or other dental conditions that cause sensitivity or allow penetration of the gel into the tooth may find that these conditions are exacerbated or have caused prolonged sensitivity after treatment with Chairside.

Gum/Lip/Cheek Inflammation – The Chairside treatment may cause inflammation of your gums, lips, or cheek margins, which is caused by inadvertent exposure to whitening gel. While this inflammation is typically temporary and subsides within days, there may be cases that can have longer recovery periods or cause greater discomfort.

I understand that after treatment, I will be required to refrain from consuming any substances that could discolor my teeth for the first 48 hours after treatment. These substances include, but are not limited to: coffee, tea, colas, ALL tobacco products, mustard or ketchup, red wine, soy sauce, berry pie, and red sauces. I understand that if I am unsure about the discoloration potential of any substance that I may consume following my Chairside procedure, I should discuss the substance with my dentist.

Here is a list of clear drinks and ‘white foods’ that are perfectly fine for eating and drinking after a treatment.

Food: Skinless chicken/turkey (minus the fat), White fish, White rice, White pasta, White cheese, Cauliflower, White onion, Egg whites, Peeled potatoes cooked to your liking, Crust less white bread, Bananas, White low-fat yogurt

Drink: Still / sparkling water, Tonic/soda water, White lemonade, Skimmed milk,Clear coconut water (not milk!), Clear alcohol mixed with clear mixers (Gin and tonic, vodka and white etc.)

Consent Form Acknowledement Summary

I understand that it is impossible to list every possible complication that may occur as a result of Chairside treatment; as such, it has been brought to my knowledge that the list of complications contained in this form is not absolutely comprehensive.

By signing this informed consent form, I acknowledge that the basic procedures of Chairside treatment, advantages and disadvantages, risks, known possible complications, and alternative treatments have been explained to me by my dentist and my dentist has answered all my questions to my satisfaction.

By signing this informed consent form, I am stating that the contents of this consent form have been fully relayed to me in the appropriate manner, and I fully understand its content.

Should I have any questions or hesitation regarding the product or procedure, please discuss with you dental professional.

I understand that Gibbs Orthodontic Associates reserves the right to refuse treatment with the Science chairside kit for any reason at any time.

I understand that Gibbs Orthodontic Associates offers Science professional whitening as an adjunct to orthodontic treatment.

By signing this form I understand and agree to continue my routine dental exams and cleanings with my general dentist as needed.

Signatures

By signing this document in the space provided I indicate that I have read and understand the entire document and that I give my permission to perform the Chairside Whitening on either my dependent or myself.

Dr. Eric Paul Gibbs

Dentist Name