INDY SMILE GROUP • FOR OFFICE USE

Printable Consent Form

Indy Smile Group
Carmel • Fishers • North Indianapolis
Printable Paper Consent Form
For Manual Signature
Tooth Whitening

TOOTH WHITENING

Tooth whitening (bleaching) is a cosmetic procedure designed to lighten the color of your teeth. It can be performed in-office or with custom take-home trays. This consent covers both in-office and at-home professional whitening options.

DESCRIPTION OF TREATMENT

In-office: A protective barrier is placed on the gums. A professional-strength bleaching gel is applied to the teeth and activated (often with light or laser). The process is repeated for 1-3 cycles, usually taking 60-90 minutes.

At-home: Custom trays are fabricated. You apply a professional bleaching gel in the trays for a specified time (often 1-2 hours per day or overnight) for 1-2 weeks.

BENEFITS

  • Lighter, brighter, more youthful-looking teeth
  • Improved self-confidence and appearance
  • Safe when performed under professional supervision
  • Non-invasive compared to other cosmetic options

RISKS AND POSSIBLE COMPLICATIONS

  • Tooth sensitivity (temporary, usually resolves within days)
  • Gum irritation or chemical burns (usually temporary)
  • Uneven whitening or white spots (may resolve over time)
  • Re-staining over time (results are not permanent; maintenance may be needed)
  • Increased sensitivity to cold or hot for a short period
  • Allergic reaction (rare)
  • Not recommended for pregnant or nursing women, children under 18 (in some cases), or those with certain dental conditions (active decay, exposed roots, etc.)

Results vary based on the cause of discoloration, your natural tooth color, and lifestyle (coffee, tea, wine, smoking). Overuse can damage enamel or cause excessive sensitivity.

ALTERNATIVES

  • No treatment / acceptance of current shade
  • Over-the-counter whitening products (less effective and potentially riskier)
  • Porcelain veneers or bonding for more dramatic and permanent color change
  • Professional cleaning to remove surface stains

PATIENT ACKNOWLEDGEMENT

  • I understand that results are not guaranteed and vary by individual.
  • I agree to follow all instructions for in-office or at-home treatment.
  • I will inform the office of any tooth sensitivity or gum irritation.
  • I understand that existing restorations (fillings, crowns, veneers) will not whiten and may need replacement for color matching.
  • I consent to the use of the recommended bleaching agent and any protective measures.

PATIENT / GUARDIAN ACKNOWLEDGEMENT AND CONSENT

I have read (or had read to me) and understand this consent form. I have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction. I understand the risks, benefits, and alternatives of the proposed treatment. I voluntarily consent to the treatment described above.

PATIENT / GUARDIAN ACKNOWLEDGEMENT AND CONSENT

I have read (or had read to me) and understand this consent form. I have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction. I understand the risks, benefits, and alternatives of the proposed treatment. I voluntarily consent to the treatment described above.

Patient / Legal Guardian Signature
Print Name
Date
Relationship to Patient (if not patient)
PROVIDER CONFIRMATION

I have explained the nature, purpose, risks, benefits, and alternatives of the proposed treatment. The patient (or guardian) appears to understand the information and has had an adequate opportunity to ask questions.

Provider Signature
Print Name & Title
Date
Witness (optional)
Signature                                               Date
Indy Smile Group • Carmel • Fishers • North Indianapolis • This is a printable paper consent form for manual signature. A signed copy is retained in the patient record.

Optimized for Letter / A4 paper. Use your browser’s print dialog (Ctrl/Cmd + P) for best results.