TLC BUTTERFLY EFFECT SPA LLC (DBA) PRETTY SMILE CUSTOMER CONSENT FORM AND RECEIPT

 
 
 
Name *
Name
Address *
Address
Phone *
Phone
Healthy teeth and gums are required for this procedure. Please see your dental professional before beginning any whitening treatment.
Do you have allergies or reactions to carbamide or hydrogen peroxide or glycerin? *
Do you have existing tooth decay periodontal disease, gingivitis or other health issues? *
Are you photosensitive to light or currently on any photosensitive medicines? *
Are you pregnant, suspect you’re pregnant or breastfeeding? *
Under the age 18? (Requires Parent Consent) *
Have you had any oral surgery or tooth extractions within the last 30-days? *
Are you wearing piercing or metal objects in your mouth? (please remove as they may turn color *
I, (the client/consumer), hereby declare that I am 18 years old or am the parent/legal guardian of the client/consumer is under the age of 18 did in fact consult with our dental professional within the last 30 days before using this self-administered over the counter teeth whitening product and or service. Furthermore, in consideration of the product, light source, service provide and other good and valuable consideration of information received regarding this product or service. I hereby release and forever discharge TLC BUTTERFLY EFFECT SPA LLC.D/B/A/ PRETTY SMILE and any other entity performing any of these services and or products provided/offered and its employees, distributors, and/or wholesalers (collectively the “vendor”) their heirs, executors administrators, successors and assigners from an and all actionable items, and I will not hold liable the above mentioned vendor for any damages, general or unforeseen, present or future, or for any adverse conditions of any type, caused directly or indirectly by the use of this product or light source. I understand that any claims, representations, and advice by TLC Butterfly Effect LLC D/B/A/ Pretty Smile professionals in regards to teeth whitening or our light source is not warranted and therefore is not guaranteed. I have read all the above declarations and consent to the use of hydrogen or carbazide peroxide and its components or light source for the use at my own risk. I understand that the use of our or any light source used is at my own discretion. I understand that in the event I fail to cancel my appointment 24-hours prior to schedule appointment a fee of $25 will be charged to resume treatments; also accept the policy that in the event of two or more scheduled treatments missed a $40 fee will charged in order to resume the packaged I purchased.
Today's Date *
Today's Date