INFORMED CONSENT OF TEETH WHITENING

INTRODUCTION

Teeth whitening is designed to lighten the color of your teeth. Significant whitening can be achieved
in the vast majority of cases, but the result can not be guaranteed.

DESCRIPTION OF PROCEDURE

Teeth whitening is a procedure designed to lighten the color of my teeth using a combination of a
hydrogen peroxide gel and a specially designed visible LED lamp. The treatment involves using the
gel and the lamp in conjunction with each other to produce maximum whitening results in the
shortest possible time. During the procedure, the whitening gel will be applied to my teeth and it will
be exposed to the light from the LED lamp for three (3) 15-minute sessions. During the entire
treatment, a plastic retractor will be placed in my mouth to help keep it open and the soft tissues of
my mouth (i.e., my lips, gums, cheeks, and tongue) will be protected to ensure they are not exposed
to either the gel or the light. Before and after procedure the shade of my teeth will be assassed and
recorded.

RISKS OF TREATMENT

Tooth Sensitivity/Pain- During the first 24 hours after teeth whitening treatment, some patients can
experience some teeth sensitivity or pain. This is normal and usually mild, but it can be worse in
susceptible individuals. In rare cases the sensitivity or pain can persist for longer periods of time in
susceptible individuals. Analgesic can help to relief the sensitivity or pain if it is getting worse.

Gum/Lip/Cheek Inflammation/Burn- Small areas of your gums, cheecks, and/or lips, can be become
irritated if they come in contact with the whitening gel. The inflammation or burn is usually
temporary and will be subside in 2 until 3 days, but may persist longer and may result in significant
pain or discomfort, depending on the degree to which soft tissue(s) were exposed to the gel. Over
the counter analgesic (NSAIDs) will give good pain relief.

Dry/Chapped Lips- The teeth whitening treatment involves three (3) 15-minute sessions during
which the mouth is kept open. This could result in dryness or chapping of the lips, or cheek margins
which can be treated by application of lip balm, petroleum jelly or Vitamin E oil.

Cavities/Leaking Fillings- If any open cavities or leaking fillings that allow gel to penetrate the tooth
are present, significant pain could result. I understand that if my teeth have these conditions, I
should have my cavities filled or my fillings replaced before do the teeth whitening treatment.

Cervical Abrasion/Erosion- These are conditions which affect the roots of the teeth when the gum
recedes, characterized by dark grooves, notches and/or depressions where the teeth meet the
gums. Even if these areas are not currently sensitive, allowing the whitening gel to penetrate the
teeth will potentially cause sensitivity. I understand that if cervical abrasion/erosion exists on my
teeth, these areas will be covered prior to my teeth treatment. I have been advised to have these
areas repaired before the procedure.

Relapse- Following teeth whitening, it is natural for the shade of your teeth to slowly over time
return to their natural shade. Teeth whitening procedure are not permanent and I understand that
in order to maintain the brighter/whiter color of my teeth I may have to (a) periodically have the in-
office whitening procedure repeated, (b) use a whitening tooth paste or other oral care products
developed to whiten teeth are available for purchase from Leading Dental Solutions and (c) follow
any additional recommendations Dr. ____________ has given me. I have also received and read the
list of foods, beverages, and other oral habits (i.e., smoking) that could cause whitening relapse.

AFTERCARE

For a minimum 24 hours after use, avoid consuming coffee, tea, cola, red wine or anything that
would leave a stain on the teeth. If you have tooth sensitivity, it will be temporary but the use of
vitamin E oil or sensitive toothpaste will bring relief immediately.

SIGNATURES

By signing this document I indicate that I have read and undesrtand the entire document and also
explanations and I give permission for teeth whitening treatment to be performed on me.

_________________________ ________________________

Name / Signature Date