One Hour Whitening Consent Release

I, , have elected to procedure. I understand this appointment will be for approximately 2 hours; one hour to prep for the procedure and one hour to complete the procedure. I am aware of the following side affects related to the whitening process:

- Degree of whitening will vary from patient to patient. There is no guarantee of any particular result.

- Possibility of sensitivity of the teeth, after the procedure is completed, which can last in duration for several months after the whitening process.

- Possibility of sensitivity of the gums, after the procedure is completed, which can last in duration for several months after the whitening process.

I have been informed the purchase of the following products might aid in the sensitivity that may occur: anti-sensitive toothpaste, Soothe RX, and a fluoride treatment (after the whitening process is completed). I understand that this is a permanent process, however, a loss of color is possible based on my living habits. I understand I may need to purchase additional whitening material to update and maintain my whitening results. I am aware this process will NOT change the color of crowns, veneers, or composite fillings I may have in my mouth prior to the whitening process.