Informed Consent For Zoom! Tooth Whitening Treatment printable pdf download

INFORMED CONSENT FOR ZOOM!

TOOTH WHITENING TREATMENT

INTRODUCTION

This information has been given to me so that I can make an informed decision about having my teeth

whitened. I may take as much time as I wish 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 my teeth are discolored and could be treated by in-office whitening

(also known as “bleaching”) of my teeth.

DESCRIPTION OF THE PROCEDURE

Zoom! in-office tooth whitening is a procedure designed to lighten the color of my teeth using a

combination of a hydrogen peroxide gel and a specially designed ultraviolet lamp. The Zoom!

treatment involves using the gel and 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 my teeth will be exposed to the light from the Zoom! 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 covered to

ensure they are not exposed to either the gel or light. Lip balm (SPF rating: 30+) may also be applied

as needed and I will be provided an ultraviolet light filter for my eyes. After the treatment is

completed, the retractor and all gel and tissue coverings will be removed from my mouth. Before and

after the treatment, the shade of my upper-front teeth will be assessed and recorded.

ALTERNATIVE TREATMENTS

I understand I may decide not to have the Zoom! treatment at all. However, should I decide to undergo

the treatment, I understand there are alternative treatments for whitening my teeth for which my dentist

can provide me additional information. These treatments include:

Whitening Toothpastes/Gels

Other In-office Whitening Treatments

Take-Home Whitening Kits

COST

I understand that the cost of my Zoom! treatment is determined by my dentist. I understand that my

dentist will inform me if there are any other costs associated with my Zoom! treatment.

RISKS OF CONSENT FOR TREATMENT

I also understand that Zoom! treatment results may vary or regress due to a variety of circumstances. I

understand that almost all natural teeth can benefit from Zoom! whitening treatments and significant

whitening can be achieved in most cases. I understand that Zoom! whitening treatments are not

intended to lighten artificial teeth, caps, crowns, veneers or porcelain, composite or other restorative

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Patient’s Initials: ________

Informed Consent For Zoom! Tooth Whitening Treatment