Teeth Whitening Waiver

Elusive Boutique & Salon · Idaho Falls, ID

Teeth Whitening Consent & Release

4406 E 17th St, Idaho Falls, ID · (Signed copy — please bring or email to the salon)

Please complete this before your appointment. It takes about two minutes and stays on your device.

Teeth whitening is designed to lighten the color of your teeth. Significant lightening can be achieved for most clients; however, results cannot be guaranteed. When done properly, the whitening process will not harm your teeth or gums. Like with any cosmetic treatment there are some inherent risks and limitations.

Your information

Please read and initial each statement

0 of 9 initialed
1.
Initial

I agree that I am over the age of 18, am NOT under the influence of alcohol or drugs, am NOT pregnant or nursing & desire to receive the teeth whitening procedure. The general nature of the teeth whitening procedure has been explained to me.

2.
Initial

I have been informed of the nature, risks, and possible complications and consequences of teeth whitening. I understand the teeth whitening procedure may have known or unknown complications including, but not limited to: tooth sensitivity, tingling, minor discomfort, & toothache.

3.
Initial

I understand that results may vary per client & any payments made are for the rendering of services and are not contingent upon individual client results.

4.
Initial

I understand that the teeth whitening procedure is not intended to lighten artificial teeth, composite, crowns, veneers, caps, porcelain or other restorative materials.

5.
Initial

I understand that if I have multiple fillings, cavities, chips, or cracks in my teeth that the teeth whitening procedure is not best suited for me & I should seek an alternative non-bleaching option.

6.
Initial

I understand that I may end up with multiple colorations or splotches due to various contributing factors.

7.
Initial

I am not pregnant or lactating.

8.
Initial

I understand that this procedure is not permanent, & exposing teeth to various staining agents will result in changes of shade post bleaching.

9.
Initial

I elect to receive this procedure from Elusive Boutique & Salon of my own free will & understand & accept all of the above information.

Photo release (choose one)

Agreement

By signing below, you agree to the following: I understand this agreement is binding & that I have read & fully understand all information listed above. I represent that I am over the age of 18, or that I have a parent and/or guardian signature below & that he/she consents to this procedure under these terms. I have completed this form to the best of my ability & acknowledge & agree to inquire about questions I may have before Elusive Boutique & Salon begins performing the procedure. I have been informed of & understand the contraindications to the requested treatments & agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform my esthetician of any discomfort I may experience during the requested treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my esthetician & Elusive Boutique & Salon for any injury or damages incurred due to any misrepresentation of my health history.

Client signature
Sign above with your finger or mouse
Only if the client is under 18 — the guardian signs above.
This form is completed on your device — nothing is sent automatically. Please save the PDF and email it to us or have it ready at your appointment.

Waiver complete — thank you!

Tap below to save a PDF copy. Please email it to the salon or have it ready at your appointment.