Consent Form For Bleaching/Whitening Information


Bleaching/whitening ("bleaching") is a procedure which is designed to lighten the color of your teeth. When done properly, bleaching will not harm your teeth or gums. Significant lightening can be achieved in most cases, but the RESULTS CANNOT BE GUARANTEED. Bleaching, like any other treatment, has some inherent risks and limitations. These are seldom serious enough to discourage you from having your teeth bleached but should be considered before a decision to have treatment.


Bleaching involves wearing a custom-made bleaching tray (looks like a thin, transparent night guard) filled with a mild bleaching gel. You need to wear the bleach-filled tray a minimum of 4 hours at night (NiteWhite®) or 30 minutes to I hour twice a day (DayWhite®) for approximately 14 days. We check your bleaching progress after one week.


Wearing Your Bleach Trays

Bleaching is only effective if you conscientiously WEAR THE BLEACHING TRAY FOR THE PRESCRIBED NUMBER OF HOURS PER DAY.


If you experience any severe discomfort or other problems, CONTACT US IMMEDIATELY.


Tooth Sensitivity

Sensitivity is usually mild if your teeth are not normally sensitive. It may be necessary for you to reduce the number of hours you are wearing the bleaching tray or stop using it for a short time to resolve the sensitivity, or we can prescribe fluoride treatments. If your teeth are sensitive after bleaching, a mild analgesic such as Tylenol or Advil will usually be effective to make you more comfortable until your teeth return to normal.

Gum Irritation

Temporary inflammation and/or a burning sensation of your gums can be caused by bleaching. This is a minor problem and will resolve by itself in a few days.

Cervical Abrasion/Erosion

These conditions affect the roots of the teeth when gums recede. They are the grooves, notches, or depressions where the teeth meet the gums that look darker than the rest of the teeth. They look darker because there is no enamel in these areas and should be filled after the bleaching is completed.

Effect on Fillings

Even though open cavities should be filled, or badly leaking fillings should be re-filled prior to bleaching, bleaching can cause tooth-colored fillings to become softer and may make them more susceptible to staining. Therefore, you should be prepared to have any fillings in your front teeth replaced after bleaching. In addition, since bleaching will normally lighten teeth, but not fillings, you may need to have your fillings replaced anyway, so that they will match your newly whitened teeth.


After the completion of bleaching, there may be a gradual relapse of the teeth back to their original color. You may choose to wear your bleaching trays once a month to keep relapse from occurring at all.

I have read and understand the procedure(s). The above information has been explained to me and I have had the opportunity to ask questions. I consent to this treatment.


Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.