Informed Consent Teeth Whitening 

Teeth Whitening Treatment Consent


I acknowledge that I am purchasing a self-administered Teeth Whitening Kit that is designed to lighten the color of my teeth.  As part of the purchase, I am asking for assistance in the application of my whitening kit, and I understand that I will be allowed to use a specially designed LED lamp provided by BronzedBerry in order to accelerate the whitening process.

Results Guarantee:

Although most natural teeth can benefit from the BronzedBerry treatment, I understand that everyone’s teeth are different and react differently to teeth whitening treatments.  For this reason, results will vary, and the only guarantee that BronzedBerry can give me is that my teeth will be noticeably whiter after the treatment. I understand t that BronzedBerry treatments are not intended to lighten artificial teeth, caps, crowns, veneers, porcelain, composite or other restorative materials.  Teeth with multiple colorations, bands, splotches or spots due to tetracycline use or fluorosis are difficult to whiten.

Potential Risks:

Although whitening treatments using over-the-counter products such as my whitening kit are generally safe, I understand that some of the potential complications of this treatment include, but are not limited to:

GUM IRRITATION: Whitening gel that comes in contact with gum tissue during the treatment may cause inflammation of whitening of the gums or gum line.  This is due to inadvertent exposure of small areas of those tissues to the whitening gel. The inflammation and/or whitening of gums is transient, and the color change of the gum tissue will reverse within 30 minutes.

TOOTH SENSITIVITY: Although uncommon with the BronzedBerry System, some customers can experience some tooth sensitivity during the first 24 hours after the whitening treatment.  People with existing sensitivity, recently cracked teeth, micro-cracks, open cavities, leaking fillings, or other dental conditions that cause sensitivity may find that those conditions increase or prolong tooth sensitivity after the BronzedBerry treatment.

SPOTS OR STREAKS: Some customers may develop white spots or streaks on their teeth due to calcium deposits that naturally occur in teeth.  These usually diminish over time.

RELAPSE: After the BronzedBerry treatment, it is natural for teeth color to regress somewhat over time.  This is natural and should be very gradual, but it can be accelerated by exposing the teeth to various staining agents, such as coffee, tea, tobacco, red wine, etc.  I should not eat or drink anything except water during 60 minutes after the treatment. I understand that the results of the treatment are not intended to be permanent and that secondary, repeat or touch-up treatments may be needed for me to maintain the color I desire for my teeth.


I understand that the BronzedBerry treatment CANNOT be used by pregnant or lactating women, people with gum disease, open cavities, leaking fillings, or other dental conditions, or people with a known allergy to peroxide.  People under the age of 18 must have parent present and sign the waiver. People that have had braces removed should wait 6 months for cement residue to wear off before using the BronzedBerry whitening treatment.

By signing this document, I indicate that I am not ineligible as per the criteria listed above, that I have read and fully understand this entire document including the possible risks, complications and benefits that can result from the treatment, and that I agree to receive assistance in the application of the treatment by a BronzedBerry certified artist under my own responsibility.  I also certify that I HAVE HEALTHY TEETH AND GUMS.

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Signature Certificate
Document name: Teeth Whitening Treatment Consent
lock iconUnique Document ID: f263e968f9f438778c71d5bcfc4e114fd9c20d44
Timestamp Audit
April 19, 2019 2:22 pm EDTTeeth Whitening Treatment Consent Uploaded by Amie Burkholder - IP