Home / New Patients / Patient Forms / Bleaching Consent

Bleaching Consent

Schedule Your Consultation Today!

Ask the doctor

leaf icon Teeth Whitening Consent

dental solutions logo

  • Informed Consent Teeth Whitening

  • When utilized properly teeth whitening procedures and products whiten teeth, to one degree or another in nearly all cases, with some whitening systems being more effective than others. As in any type of dental treatment, specific results cannot be guaranteed. Scientific studies have shown that when used properly, professional teeth whitening products will not harm you teeth or gums, however there are certain inherent risks and limitations. Most often the risks are not serious enough to prevent you from whitening your teeth.

    Most people are candidates for whitening, however some teeth whiten more effectively than others. Teeth with opaque spots, due to various causes, may result in the spots becoming noticeably lighter than the surrounding tooth color. Opaque spots will whiten much faster than the rest of the teeth, however if a highly effective technique such as KoR Whitening Deep Bleaching is utilized, the surrounding structure will usually whiten enough that these spots are not readily noticeable to others.

    Teeth with dark spots most often respond very well to KoR Whitening Deep Bleaching, however there is always the possibility that the dark spots will not whiten to exactly the same color as the surrounding tooth.

    All natural teeth have a different shade/color when comparing the gumline area to the tip of the tooth (gumline areas are typically darker than the rest of the tooth). This is a natural appearance found on all natural teeth. After teeth whitening, a difference in color when comparing the gumline area of the tooth to the tips of the teeth will still be apparent. The more effective the whitening technique that you select (such as KoR Deep Bleaching), the less this difference in color will be. However, regardless of technique, there will always be some difference in color from the gumline to the tips of the teeth.

    All patients have different cosmetic desires, expectations and requirements. If upon completion of whitening, the teeth have not whitening to the full desire of patient, if there are opaque white spots that are still more noticeable than the patient desires, or if there are dark spots that are still more noticeable than the patient’s desire, additional cosmetic treatment may be necessary at an additional charge.

    Sensitivity of gums and/or teeth during whitening is common. Typically this sensitivity will last only a day or two after completion of whitening. You may be given products to reduce teeth sensitivity at home, however even with the desensitizing products you may still experience some sensitivity.

    It is important to understand that tooth-color fillings and porcelain crowns will not whiten like natural teeth, and may need to be replaced after teeth whitening if the color discrepancy is noticeable.

    Exceptionally whitening-resistant teeth - including, but not limited to tetracycline stained or fluoride stained teeth require longer treatment times than average cases, and in some cases require additional inoffice whitening procedures. This is variable, and the time frame and number of necessary in-office visits cannot be known with certainty prior to the beginning of treatment. If the time necessary and the number of in-office whitening sessions are more than anticipated, additional charges may apply.

    One-Hour Whitening- This method of teeth whitening actually takes a little longer than just one hour. The advantages of this technique are that the results are achieved quickly, without need for wearing whitening trays at home. The disadvantage is that all types of one-visit of one-hour whitening are highly unpredictable, regardless of the products used, and any result has the potential to fade within a short time.

    At-Home Whitening- This method of teeth whitening requires the wearing of custom-made whitening trays to be worn by the patient at home every day or every night for one or more weeks. The advantage of this technique is that it is more predictable and longer lasing than one-hour whitening. The disadvantage is that the whitening results vary significantly, are not immediate and that it does require more time and effort on

    KoR Whitening Deep Bleaching- this method typically requires one or more in-office whitening sessions AND at-home wear of the unique custom make KoR Deep Bleaching Trays. The advantage is the most predictable, effective and long-lasting whitening effect possible. This disadvantage is higher cost, and more time and effort on the part of the patient. the part of the patient.

    To achieve permanent whiteness of you teeth, KoR Whitening Deep Bleaching must be maintained by periodic wearing of the custom KoR Maintenance Gel at home as prescribed by dentist. Without the prescribed maintenance, the whiteness of the teeth will fade with time. Depending on the results achieved, the dentist may recommend optional "accelerated maintenance" to “set” the new whiter color of your teeth.

    The Procedure will ONLY be effective if you closely follow the instructions given and conscientiously wear your whitening trays as directed.

    If you experience significant discomfort or any other problem that prevents you from wearing you trays, please contact our office immediately.

    I have read and understand the above information, I have received written and verbal instruction, explanation from the dental office staff, and I have had the opportunity to ask questions. I will consent to the planned teeth whitening procedure.

  • MM slash DD slash YYYY

After submitting, feel free to return to the Patient Forms page. Please note, there are multiple forms for each section.


Schedule Your Consultation Today!

Skip to content