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Tooth Whitening Consent Form

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"I've been going to the Smile Cliniq for the past couple of years, and the treatment, care and advice from Chetan and his team has been faultless. Highly recommended." - A.S.
"Yet again I have been blown away by Smile Cliniq. After my filling fell out on Sunday night, I was distraught. But I phoned the Cliniq in the morning and got an appointment for the same morning. Dr Kaher put me at ease, even though I was very anxious, and did an amazing job on my..." - Robyn B
"What a great dental clinic! I was having issues with a tooth and Dr Sarita Kotecha was brilliant. Solved my dental issue quickly and explained everything in a way that made me actually enjoy the appointment (!!). They were able to squeeze me in last minute too. Highly recommend t..." - Saya Jones
"The service was so good at Smile Cliniq by Dr Sarita Kotecha, I recommended my wife to change dentist. We've been looking for a good dentist since moving to London 2 and 1/2 years ago and the quality we had received from our previous dentist was sub-standard. That all changed at ..." - Greg Jones
"I have had a dentist phobia for many years and would shake all over whenever I was there. Dr Chetan Kaher changed that. He was calm and very patient and understanding of my anxiety. All the staff are thoughtful and friendly. I don't shake anymore, which is wonderful. I still have..." - DEBRA MERRITT
"Fantastic service, professional and top notch technology. Very hygenic and Dr Chetan Kaher has a very steady and experienced hand. Highly recommend." - Amrita Chauhan
"I have had a dentist phobia for many years and would shake all over whenever I was there. Dr Chetan Kaher changed that. He was calm and very patient and understanding of my anxiety. All the staff are thoughtful and friendly. I don't shake anymore, which is wonderful. I still have..." - DEBRA MERRITT
"Friendly and helpful manager. Dentist was also friendly and efficient,Gave me lots of advice about dental care showing video." - Filippa Milioto
"Needed an emergency appointment, I was seen the same day! Great service and friendly staff" - Elena Milioto
"I found the the team at smile very professional and friendly, nothing was too much trouble. Chet presented all the options and my selected course of treatment took place over a year. As it involved one of my front top teeth I had some concerns and Chet was always available to ans..." - Irin Wu
"I have a hereditary tendency to get dental cavities, ensuing painful dental treatments, which left me scared of visiting dentists. Now, in my early thirties, I did everything to avoid dental checks. I also gave up on having cavity-free teeth. Two years ago, I was forced to find a..." - Rukmini
"I have just finished my year long lingual brace treatment with Dr Sarita Kotecha which has been a huge success. I'm so happy with the results! The staff at Smile Cliniq have always been friendly, helpful and welcoming; fitting me in for last minute appointments when necessary and..." - Maayan Bianca
"My wife needed to see a dentist on an emergency basis on a Saturday after a bad fall the evening before. We called on Saturday morning and they were able to take us that afternoon. The quality of care, both technically and inter-personally, could not have been better. If we lived..." - Hal N.

This information is to help you make an informed decision about having tooth whitening. You should take as much time as you wish to make the decision in relation to signing the following consent form. You are encouraged to ask any questions, and have the answers to your satisfaction before you give permission for the whitening.

Home Tooth Whitening

Your dentist will take an impression (mould) of your teeth to construct a tooth whitening tray.  These trays ensure that there is minimal leakage and maximum cosmetic effect.  Once constructed the trays will be checked for accuracy of fit and specific instructions will be provided on your tooth-whitening regime. Customised trays are loaded with the easily applicable carbamide peroxide and worn for 2-4 hours (although they can be kept in overnight) for 4 days or longer.

In Chair Whitening

The dentist isolates your teeth from your cheeks and gums and applies a stronger hydrogen peroxide whitening gel.  This will be activated with a special light.  Due to the strength of the gel, results are much quicker than home whitening.

INFORMED CONSENT FOR TOOTH WHITENING TREATMENT

Smile Cliniq provides this information to give you insight into tooth whitening. Your cooperation and understanding of this material is necessary as we strive to achieve the best results for you.

Risks: All forms of health treatment, including tooth whitening, have some risks and limitations.  Complications that can occur in home tooth whitening are infrequent and are usually minor in nature.

Tooth Sensitivity: During the whitening process some patients may experience tooth sensitivity.  This is normal and generally mild if your teeth are not normally sensitive. If your teeth are normally sensitive, please inform your Dentist before treatment. Please let your Dentist know if you experience any discomfort during or after the procedure. A mild analgesic will usually be effective in eliminating any discomfort. A desensitising toothpaste/mouth wash will also help symptoms.

Gum and soft tissue irritation: Whitening may cause inflammation of your gums, lips or cheek margins. This is generally the result of the whitening gel coming into contact with these tissues. If any irritation does occur, it is generally short in duration and is very mild. Rinsing with warm salt water can relieve it.

Existing restorations: White fillings; porcelain or composite restorations, crowns or veneers will not whiten with your natural teeth during this procedure. This will have been discussed with you by your Dentist and replacement of these restorations may have been recommended.

Defective fillings/Cavities:   If these are present the gel may leak into the cavities, between the defective fillings and tooth, which may cause some discomfort.  In the worst case it may lead to the need for root canal treatment.  It is strongly advised any cavities, decay, defective fillings are treated before any cosmetic tooth whitening is carried out.

Expectations: Significant whitening can be achieved in many cases, but there is no absolute way to predict how light your teeth will get. Exact results are not guaranteed. Teeth with multiple colourations, bands or spots due to tetracycline staining or fluorosis do not whiten as well and may appear more spotted after treatment. These may require further treatment to achieve a uniform result in the form of veneers.  A patchy appearance of teeth with white spots may occur after whitening, this usually blends in after a few weeks.

Relapse:  Tooth whitening is not permanent and teeth may regress in shade somewhat.  This is natural and is dependent on diet.  To maintain teeth at their optimal whiteness, it is advised to avoid staining foods, drinks and smoking, i.e. coffee, tea, red wine and curries.  Repeat treatments may be needed to maintain the tooth colour you desire.

Alternative options: Scale and polish or air abrasion can improve tooth colour by removing surface staining. Crowns and veneers can change the shade as well as the shape of the teeth, however, they involve shaving part of the tooth away and replacing with porcelain.

Tooth whitening is not recommended for pregnant or lactating women, children under 14 years of age or any persons having known peroxide allergies.

I understand that the outcome of my whitening treatment cannot be guaranteed.

I understand during treatment and for 48 hours after, I will be required to refrain from consuming any chromogenic substances (i.e. tomato sauce, coffee, all tobacco products).

If any problems are experienced whilst using the product you will discontinue use immediately and consult your Dentist.

You will not use the product if you are pregnant or a nursing mother or allergic to peroxide products.

POST-OP INSTRUCTIONS: TOOTH WHITENING

Follow instructions from your Dentist.

If you are a smoker, do not smoke for 48 hours.

Stay away from highly coloured foods (red sauce, carrot juice, blueberries, curries, etc.) and beverages (coffee, tea, etc.) for 48 hours.

Sensitivity to hot or cold liquids may occur. This usually passes within 1-7 days after completion of treatment and during treatment sensitivity can be reduced by filling your trays with a “sensitive” toothpaste for an hour a day and brushing with a sensitive toothpaste such as Colgate sensitive Pro-Relief or Sensodyne, or placing the said toothpastes on the teeth overnight.

If sensitivity is severe or persists, contact your Dentist.

Whitening may cause inflammation of your gums, lips or cheek margins.  This is generally the result of the whitening gel coming into contact with these tissues. If any irritation does occur, it is generally short in duration and is very mild. Rinsing with warm salt water can relieve it.

If you experience gum sensitivity do not brush the affected area while brushing your teeth, instead use  an antiseptic mouthwash like Curasept.

Immediate whitening results can be quite dramatic due to minor dehydration of your teeth.  It is normal for the colour to tone down somewhat after treatment when your teeth rehydrate to a natural white tone.

Long term results vary from patient to patient. This can depend on the original shade of your teeth and include habits such as smoking or drinking coloured beverages (red wine, coffee, tea, etc.)

“Touch-up” treatments may be needed every 6-12 months to retain colour. You can ask your Dentist about different “touch-up” options

Existing fillings and crowns, etc. will not whiten. Therefore, these may need to be changed in order to match your new smile

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Smile Cliniq Limited. A company registered in England and Wales. Company number 08279068.

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