I have been given this information in order that I may be able to make an informed decision about undergoing a teeth whitening procedure. I am able to take as much time as I need to come to a decision whether or not to sign this informed consent form. I am free to ask any questions about any procedure before I consent to accepting treatment or undergoing any procedure. My dentist has informed that my teeth are stained and could be treated by in-office or take-home whitening, or "bleaching."


Teeth whitening is designed to lighten the color of teeth. I understand that significant whitening can be achieved in the vast majority of cases, but that results cannot be guaranteed. I understand that when done properly, the whitening will not harm my teeth, gums or soft tissues. However, like any other treatment, I understand that it has some inherent risks and limitations, which are seldom serious enough to discourage me from having my teeth whitened, but should be considered when deciding to have the treatment.


Just about anyone is a candidate for teeth whitening. However, I understand that dark yellow or yellow-brown teeth tend to have better results than gray or bluish-gray teeth. I understand that multi-colored teeth, especially if stained due to tetracycline, do not whiten very well. I also understand that teeth with many fillings, cavities, chips, etc. are usually best treated by bonding LUMINEERS, porcelain veneers or porcelain crowns.



    I understand that this process can be done in one visit or may require multiple visits depending on how my teeth respond to the whitening gel. I understand that each appointment takes about one hour and that during the procedure, gum protection is applied, the whitening gel is applied, and a special light may or may not be used.

    I understand that the advantages of professional chairside whitening include having professionals do all the work for me and in less total time than I would spend whitening my teeth with a home whitening system. I also understand that the disadvantages include the normal inconveniences of any dental treatment, such as having to keep my mouth open for the duration of the appointment and the total time in office.


    I understand that this process, which can be done anywhere and anytime, involves wearing a custommade whitening tray filled with a mild whitening gel for optimal results. I understand that I should wear the gel-filled tray about three minutes per day for about one to two weeks for 32% concentration, and once or twice a day for 1-2 hours for two weeks for 22% and 16% concentrations. I understand that the advantages of home whitening include performing the treatment when it is convenient for me. I also understand that the disadvantages of home whitening is that the success of the treatment is dependent on my commitment to wearing the whitening tray for a prolonged treatment time.


I understand that I may choose not to receive the discussed whitening treatment at all, that other treatment options are available, and that I am free to ask about or choose alternative options.


I understand that the cost of my whitening treatment is determined by my dentist and that my dentist will inform me of any additional costs associated with my whitening treatment.



    I understand that if I choose home whitening, it will only be effective if I conscientiously wear the tray for the prescribed period.


    I understand that if I experience any severe discomfort or other problems, I will discontinue the whitening and contact the dentist immediately. I understand that most sensitivity is usually transient and disappears after one to several days.


Tooth Sensitivity/Pain – I understand that during the first 24 hours following whitening, some patients experience transient sensitivity or pain and that this sensitivity or pain is usually mild if my teeth are not normally sensitive. I understand that with professional chairside whitening, this sensitivity or pain will usually subside in 1-2 days. I also understand that with home whitening, it may be necessary for me to reduce the number of applications or stop using it for several days to resolve the issue.

However, I understand that if my teeth are normally sensitive, whitening may make my teeth more sensitive for an extended period of time. Under these circumstances, I understand that I may choose to delay the whitening process until my dentist is able to complete desensitization procedures.

If my teeth are sensitive after whitening, I understand that a mild analgesic, such as Tylenol or Advil, will usually be effective in making me more comfortable until my tooth sensitivity returns to normal.

GUM/LIP/CHEEK IRRITATION – I understand that it is possible that a small amount of solution may leak under the gum protection or come in contact with my lips or cheeks, resulting in irritation, that a burning sensation may occur, and that this should resolve by itself within a few hours to a few days.

I understand that with home whitening, irritation can result from using the tray for too long when I first start whitening. I understand that it may be necessary for me to reduce the amount of time I wear the tray or stop using it for a few days to resolve these problems.

EFFECT ON CAVITIES OR FILLINGS – I understand that tooth-colored fillings will not whiten and that if the filling matched my current color, whitening will result in mismatched shades with my natural teeth. If that is the case and I choose to proceed with whitening, I understand that I may need to have my fillings replaced to match my newly whitened smile.

I understand that open cavities or fillings that allow gel to penetrate the tooth could result in considerable pain. I understand that if these conditions exist in my teeth, I should have my cavities filled or my fillings redone before proceeding with the whitening treatment.

DRY/CHAPPED LIPS – I understand that certain whitening treatments require durations of time in which my mouth is continuously kept open, which could result in dry or chapped lips or cheeks and that this condition can be treated by applying lip balm, petroleum jelly or vitamin E cream.

CERVICAL ABRASION/EROSION – This is a condition where the gum line has receded, exposing the base of the teeth, which is darker because there is a lack of enamel. These areas can allow whitening gel to penetrate the teeth and cause sensitivity. I understand that if my teeth have cervical abrasion/erosion, these areas will be covered with a protective barrier before my teeth are treated.

ROOT RESORPTION - This condition is characterized by a breakdown and subsequent loss of a tooth’s root structure. I understand that evidence exists that indicates this condition is higher in patients who undergo whitening after having root canals.

RELAPSE – I understand that following completion of whitening, pigments found in food and drinks will re-stain my teeth, commonly called bleaching relapse. I also understand that I can help prevent relapse by using a daily over-the-counter toothpaste.


LEVEL OF WHITENING - I understand that there is no totally reliable way to predict how light my teeth will whiten. I understand that with professional chairside whitening, one session usually significantly whitens my teeth, but that some patients require an additional session. I also understand that with home whitening, treatment may take two to four weeks or longer of repeated applications.

I understand that safety, efficacy, potential complications and risks of the discussed whitening treatment can be explained to me by my dentist and that more information on this and alternative whitening treatments will be provided to me upon my request. I understand that the list of complications in this form is not comprehensive because it is not possible to state every complication that whitening may cause.


By signing this informed consent, I am stating that I have read the information provided in this informed consent (or it has been read to me), the procedure has been explained to me, I understand the procedure, with its possible risks, complications and benefits, all my questions have been answered to my satisfaction, and I consent to undergo this whitening treatment.