Informed Consent For Zoom! Tooth Whitening Treatment (Page 3 of 4) in pdf

Cavities or Leaking Fillings – Most dental whitening is indicated for the outside of the teeth, except

for patients who have already undergone a root canal procedure. If any open cavities or fillings that

are leaking and allowing 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 re-

done before undergoing the Zoom! treatment.

Cervical Abrasion/Erosion – These are conditions which affect the roots of the teeth when the gums

recede and they are characterized by grooves, notches and/or depressions, that appear darker than the

rest of the teeth, where the teeth meet the gums. These areas appear darker because they lack the

enamel that covers the rest of the teeth. Even if these areas are not currently sensitive, they can allow

the whitening gel to penetrate the teeth, causing sensitivity. I understand that if cervical

abrasion/erosion exists on my teeth, these areas will be covered with dental dam prior to my Zoom!

treatment.

Root Resorption – This is a condition where the root of the tooth starts to dissolve either from the

inside or outside. Although the cause of this is still uncertain, I understand that there is evidence that

indicates the incidence of root resorption is higher in patients who have undergone root canals

followed by whitening procedures.

Relapse – After the Zoom! treatment, it is natural for the teeth that underwent the Zoom! treatment to

regress somewhat in their shading after treatment. This is natural and should be very gradual, but it can

be accelerated by exposing the teeth to various staining agents. Treatment usually involves wearing a

take-home tray or repeating the Zoom! treatment. I understand that the results of the Zoom! treatment

are not intended to be permanent and secondary, repeat or take-home treatments may be needed for me

to maintain the tooth shade I desire for my teeth.

The safety, efficacy, potential complications and risks of Zoom! treatment can be explained to me by

my dentist and I understand that more information on this will be provided to me upon my request.

Since it is impossible to state every complication that may occur as a result of Zoom! treatment, the list

of complications in this form is incomplete.

The basic procedures of Zoom! treatment and the advantages and disadvantages, risks and known

possible complications of alternative treatments have been explained to me by my dentist and my

dentist has answered all my questions to my satisfaction.

In signing this informed consent I am stating I have read this informed consent (or it has been read to

me) and I fully understand it and the possible risks, complications and benefits that can result from the

Zoom! treatment and that I agree to undergo the treatment as described by my dentist.

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Patient’s Initials: ________

Informed Consent For Zoom! Tooth Whitening Treatment Page 3