Informed Consent For Zoom! Tooth Whitening Treatment Page 4
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4SIGNATURES
By signing this document in the space provided I indicate that I have read and understand the entire
document and that I give my permission for Zoom! treatment to be performed on me.
________________________________________
_________________
PATIENT’S SIGNATURE
DATE
________________________________________
_________________
PATIENT’S NAME (PRINTED)
DATE
_______________________________________
_________________
DENTIST’S SIGNATURE
DATE
_______________________________________
_________________
DENTIST’S NAME (PRINTED)
DATE
Page 4 of 4
Patient’s Initials: ________
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