Teeth Whitening Consent Form

This information is to help you make an informed decision about having a teeth whitening treatment. 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 up to 11 hours for 4 days. You are advised to attend for a follow up visit.

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.

Internal Bleaching

This procedure is recommended for teeth that have had root canal treatment in the past and as a result of this or trauma, have become discoloured and no longer match the surrounding teeth. The procedure involves making a small access opening through the previous root canal entry, placing bleaching material into the cavity of the tooth, and sealing the area off afterward. The bleach is placed in the cavity and heated up. Please bear in mind results cannot be guaranteed.


This information is provided in order to give you insight into teeth 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 (painkiller) will usually be effective in eliminating any discomfort. A desensitising toothpaste/mouth wash may 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, replacement of these restorations may have been recommended.

Defective fillings/Cavities: IF these are present the gel may go 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 replaced before any cosmetic tooth whitening is carries 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.

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.

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

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

I understand during treatment, 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.


Follow instructions from your Dentist.

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

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

Mild sensitivity to hot or cold liquids may occur. This usually passes within 1-2 days and can be improved by filling your trays with a “sensitive” tooth paste for an hour a day and brushing with a sensitive toothpaste.

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 afflicted 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.

Tap or click on the signature above to sign

Data Protection and Privacy

We are committed to protecting your privacy. We take special precautions with your sensitive personal data and we will process your data lawfully and as described. We only process the data we need for as long as we need to and we respect all of your rights under GDPR. We will never sell, share or otherwise abuse your data. You can contact us at anytime to request your data, change your preferences or request that your data be deleted. GDPR is the European privacy law designed to protect you and give you control of your data.