INTRODUCTION This information has been given to me so that I can make an informed decision about having my teeth whitened, I may take as much time as I need to make my decision about signing this informed consent form. I have the right to ask questions about LA Smile whitening treatment before agreeing to undergo the procedure

DESCRIPTION OF THE PROCEDURE LA Smile uses is designed to lighten the color of my teeth using a combination of a peroxide based gel and a specially designed lamp. The treatment involves using the gel and lamp in conjunction with each other to produce the whitening action. During the procedure, the aesthetician will apply hydrogen peroxide (H²0²⁾) and silicon dioxide (Si0²) to my teeth and my teeth will be exposed to the light from the lamp for approximately 3-4 15 min sessions. During the entire treatment, I will place a plastic retractor in my mouth to help keep it open. I will also apply lip protection cream as needed and I will be provided a pair of protective eyewear to use during the treatment. After the treatment is completed, I will remove the retractor and eyewear and I will be instructed to rinse my mouth with water. Before and after the treatment, the shade of my front teeth will be assessed, shown to me, and recorded.

RISKS OF CONSENT FOR TREATMENT I also understand that the LA Smile Select treatment results may vary or regress due to a variety of circumstances. I understand that almost all natural teeth can benefit from the L.A Smile whitening treatment and significant whitening can be achieved in most cases. I understand that L.A Smile whitening treatments are not intended to lighten artificial teeth, caps, crowns, veneers or porcelain, composite or other restorative materials and that people with darkly stained yellow or yellow-brown teeth frequently achieve better results than people with gray or bluish-gray teeth. I understand that teeth with multiple colorations, bands, splotches or spots due to tetracycline use or fluorosis may have less dramatic whitening results. I understand that teeth with many fillings or cavities may not lighten.  I understand that the L.A Smile treatment is not recommended for pregnant or lactating women, or clients under the age of 16 years. I understand that the LA Smile Select treatment cannot be undergone if I have an allergy to peroxides or glycols.

I understand that the results of my treatment cannot be guaranteed.

I understand that whitening treatments are considered generally safe by most dental professionals and are sold over-the-counter to individuals. I understand that although my aesthetician has been trained in the proper use of the  LA Smile system, the treatment is not without risk. I understand that some of the potential complications of this treatment include, but are not limited to:

Tooth Sensitivity– During the first 24 hours after the LA Smile Select treatment, some clients can experience some tooth sensitivity. While uncommon with the LA Smile Select system, tooth sensitivity is a common side effect of peroxide-based tooth whitening. It is usually mild, but it can be worse in susceptible individuals. Normally, tooth sensitivity following the use of peroxide-based whitening products subsides within 24 hours. People with existing sensitivity, recently cracked teeth, abfractions (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 L.A Smile Select treatment.

Gum Irritation – In rare cases, whitening gel may come in contact with the gum tissue during the treatment and may cause inflammation or whitening of my gums or gum line. This is due to inadvertent exposure of a small area of those tissues to the whitening gel and the inflammation and/or whitening is usually temporary and will subside almost immediately, with color change in the gum tissue reversing within 30 minutes.

Dry Lips –L.A Smile Select treatment involves periods during which the mouth is kept open continuously for the entire treatment by a plastic retractor. This could result in dryness or chapping of the lips or cheek margins, which can be treated by application of lip balm, petroleum jelly, or Vitamin E cream.

Relapse – After the L.A Smile Select treatment, it is natural for the teeth to regress somewhat in their shading over time. This is natural and should be very gradual, but it can be accelerated by exposing the teeth to various staining agents. I understand that the results of the treatment are not intended to be permanent and that repeat or touch-up treatments may be needed for me to maintain the tooth shade I desire for my teeth.

In signing this informed consent I am stating I have read this informed consent (or it has been read to me) and I fully understand it and the possible risks, complications and benefits that can result from the LA Smile Select treatment and that I agree to undergo the treatment as indicated by the printed instructions provided to me by my aesthetician.