teeth whitening 
consultation form

to provide you with a very safe service with the best possible results please provide the following information

Description of the Procedure

The whitening treatment is a cosmetic procedure designed to whiten the colour of your natural teeth using a combination of a 6% hydrogen peroxide food grade whitening gel and a specially designed LED lamp.  The treatment involves using the whitening gel and a lamp in conjunction with each other to produce maximum whitening results in the shortest possible time.  During the treatment, the whitening gel will be applied to your teeth and your teeth will be exposed to the LED lamp for up to three (3) 15 minute sessions.  During the entire treatment, a plastic cheek retractor will be placed in your mouth to help keep it open.  An oral cleansing wipe and vitamin e swab  will be used to help cleanse, hydrate and protect the soft tissues of your mouth (eg, lips, gums, etc.) and you will use a pair or protective glasses to help protect your eyes from the LED lamp.  After the treatment is completed, the retractor and eyewear will be removed, and you will rinse your mouth with water to remove the whitening gel.  Before and after the treatment, the shade of your smile line will be assessed and recorded.


No Results Guarantee

Although most natural teeth can benefit from a teeth whitening treatment, please understand that everyone's teeth are different and that results will vary.  I understand that people with yellowish teeth generally get the best results and that if your teeth have a spots due to tetracycline use (greyish tint) or fluorosis, these will be difficult to whiten.  Also if you have artificial teeth, caps, crowns, veneers, porcelain, composite or other restorative materials, you shouldn't expect dramatic results from this treatment because the peroxide gel will not whiten artificial dental work.  Please be aware that your teeth will never be whiter than the the white colour of your genes naturally allow.  As with all other over-the-counter teeth whitening kits, you should discuss your own dental health with your dentist prior to using the treatment.


Potential Risks / Side Effects

Although whitening treatments are generally safe please understand that some of the potential complications include but are not limited to:

Tooth Sensitivity:    Although uncommon, some people can experience some tooth sensitivity during the first 24 hours after the treatment.  This is normal and is usually mild and subsides within 24 hours, but it can be worse in susceptible individuals.  People with existing sensitivity, recently cracked teeth, micro-cracks, open cavities, leaking fillings, exposed roots, or other dental conditions that cause sensitivity may find that those conditions increase or prolong tooth sensitivity after the treatment.  

Gum/Lip Irritation:  Whitening gel that comes into contact with gum tissue or the lips during the treatment may cause inflammation or whitening in the areas. This is due to inadvertent exposure of small areas of the tissues to the whitening gel. The inflammation and/or: whitening of the gums are transient, and the colour change of the gum tissue will reverse within 30 minutes.  You may feel a stinging and tingling sensation on these soft tissues during the treatment if the whitening gel comes into contact with them.

Spots or Streaks:  Some people may develop white spots or streaks on their teeth due to calcium deposits that naturally occur in teeth.  These spots are not caused by the whitening gel.  The whitening gel brings the already existing calcium deposits out and makes them visible again.  These usually diminish over time.  

Dry/Chapped Lips:  The treatment involves up to three (3) 15 minute sessions during which the mouth is kept open with a plastic cheek retractor for the entire treatment.  This can result in dryness or chapping of the lips, which can be treated by application of a lip balm or vitamin E cream.

Relapse:  After the treatment, it is natural for the teeth to regress somewhat in their shading over time.  This is natural and should be gradual, but it can be accelerated by exposing the teeth to various staining agent, such as coffee, tea, tobacco, re wine, colas etc.  Please understand that you should not eat or drink anything except water for 2 hours after the treatment be cause the whitening gel opens the pores of your enamel and makes your teeth very vulnerable to staining agents.  Only 24 hours after the conclusion of the treatment can you resume your normal habits.  Please understand that the results of the treatment are not intended to be permanent and that repeat or touch-up treatments may be needed for you to maintain the shade colour you desire for your teeth.

Eligibility for Use:

Please understand that this treatment cannot be used by certain persons, including pregnant or lactating woman, people under the age of 16, people with gum disease, loose or decayed teeth, open cavities, overly sensitive teeth, leaking fillings, cracked teeth, exposed roots or other dental health issues that are within the smile line that are going to be whitened or people with known allergies to hydrogen peroxide or any other ingredient contained in the products.  People that have had braces removed should wait 6 months for cement residue to wear off before undergoing the treatment and people with a piercing or other metal objects in the oral cavity should remove these objects before the treatment as they may turn black.  If you feel a sharp pain on a particular tooth during the treatment you will advise your therapist administering the treatment immediately.  


Dermal Remedy is not the manufacturer of the products used for the treatment, but is a reseller of the products. To the fullest extent permitted by law, Dermal Remedy does not provide any guarantee or warranty in relation to the products or the treatment, including (but not limited to) in relation to any actual or expected results or any possible side effects, changes or damage to teeth or gums or oral tissue in connection with the treatment or use of products.  

Please understand you must consult with your won dentist, physician or medical practitioner regarding the treatment, the products and/or equipment or in relation to any information contained in the consent before undergoing the treatment.  Understand that Dermal Remedy does not give or intend to give any answers or advice relating to medical relating question and this consent does not replace or substitute any professional medical advise.  Dermal Remedy does not represent itself as being a dentist, physician or other medical practitioner and this is not implied.  Please understand your dentist, physician or medical practitioner should address any and all medical questions, concerns and decisions regarding the treatment, use of the products and the equipment and possible treatment of any relevant medical condition.

If you are in need of medical attention, call your dentist or medical practitioner immediately.

Informed Consent


This information is being provided to me so that I can make an informed decision about having my teeth cosmetically whitened.  I acknowledge that I am receiving a Teeth Whitening treatment from Dermal Remedy, which includes a teeth whitening gel  containing 6% hydrogen peroxide (made in USA) designed to whiten the color or my natural teeth in my smile line, a plastic cheek retractor, Vitamin E swabs and an oral cleansing wipe.  The teeth whitening treatment will be administered at the discretion of an experienced teeth whitening technician at Dermal Remedy, which I understand will involve the provision and use of a specially designed LED lamp to accelerate the whitening process and a pair of protective glasses.

Signature and Acknowledgement:

By signing this document, I acknowledge and agree that:

  • I am eligible to use the Treatment, the Products and the Equipment;

  • the Treatment is not being prescribed or administered by a dental practitioner and I confirm I have read and fully understood all information and all terms and conditions contained in this document prior to signing this document, including (but not limited to) the eligibility criteria specified and the possible risks, side effect, complications and benefits that can result from the Treatment, the Products and the Equipment;

  • the Products and Equipment used are solely for the purpose of whitening teeth;

  • I accept all the risks associated with the Treatment and the use of the Products and Equipment and, to the fullest extent permitted by law, absolutely release Dermal Remedy and or suppliers, form any loss, damage or liability whatsoever in relation to or in connection with the Treatment and/or Products and Equipment; and

  • I am receiving this Treatment with the use of Products and the Equipment at my own risk and under my own responsibility.

  • I also confirm that I HAVE HEALTHY TEETH AND GUMS and have no reason to believe otherwise.

Thanks for submitting x