Teeth Whitening Waiver
General. I hereby acknowledge that I am having a Professional Tooth Whitening service done
at Glitz Spray Tanning, which is designed to whiten the color of my teeth.
Results Guarantee. Although most natural teeth can benefit from tooth whitening treatments, I
understand that everyone’s teeth are different and that results vary. I understand that people with
yellowish teeth generally get the best results, and that if my teeth have grayish spots from
tetracycline use, or flourosis, these will be difficult or even impossible to whiten. I further understand
that if I have artificial teeth, caps, crowns, veneers, porcelain inlays, composite fillings, or other tooth
colored restorative materials, I should not expect dramatic results from this treatment because the
peroxide gel will not whiten (or damage) restorative dental materials. I am also aware that my teeth
will never be whiter than is possible, which is determined by the nature of my fixed genetic tooth
composition
Potential Risks. Although Tooth Whitening treatments are generally considered
routine and safe there are rare cases of complications. I understand that some of the potential
complications of this treatment may include, but are not limited to:
Tooth Sensitivity. Although uncommon, you may experience some tooth sensitivity during the first
24 hours following your whitening treatments. If your teeth are already sensitive, or you have cracks,
fissures, open cavities, leaking fillings or crowns, exposed roots or other dental conditions that cause
tooth sensitivity, you may experience increased sensitivity during and/or prolonged sensitivity
following your whitening treatments. Please inform your Technician if you experience any change in
sensitivity during your whitening treatments
Spots or Streaks. You may develop white spots or streaks on your teeth due to calcium deposits
that occur naturally in your teeth. The peroxide gel and/or the whitening process do NOT cause
white spots or streaks. The whitening process has only made your existing calcium deposits visible
again, and they will usually diminish over time. (24 Hours).
Relapse. After your treatments, it is natural for your teeth to regress in color over time. This is part of
a natural aging process. The more you expose your teeth to various staining foods and beverages,
such as coffee, tea, tobacco, red wine, cola, dark juices, the more you re-stain and darken your
teeth. Just remember, anything you eat or drink, that would stain a white cotton shirt, will stain your
teeth. We will provide you with After Care Instructions, and Dietary Suggestions that will help you
keep your teeth whiter for longer.
We suggest that you consume only water for the first hour and avoid staining beverages for the first
24 hours.