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.