11550 Jonesbridge Rd, Suite# 6, Alpharetta GA 30022
Email: info@cosmomedspaatl.com         Tel: (678) 829-7722

Teeth Whitening Consent Form


  • I understand that my teeth whitening treatment cannot be guaranteed, as teeth whiten differently for each individual depending on his or her genetic traits and types of stains.
  • I understand that my teeth whitening treatment is not intended to whiten artificial teeth, caps, crowns, veneers or porcelain, composite or other restorative materials.
  • I understand that the longevity of my whitening results will vary based on the types of food and drink that I consume, brushing habits, and optional maintenance with other whitening maintenance products.
  • I understand that all forms of health treatment, including teeth whitening, have some risks and limitations. Complications can occur, but are infrequent and usually minor.
  • I understand that the whitening product is designed for minimal to no sensitivity, but during or after the whitening process some patients may experience sensitivity which is normal, temporary and generally mild. A mild analgesic will usually be effective in eliminating any discomfort.
  • I understand that whitening may cause inflammation of gums, lips and/or cheek margins. I may see a white film on my gums after the procedure which is a normal and temporary reaction to hydrogen peroxide. Protective materials are placed in the mouth to prevent this, but despite the best efforts, it can still occur. If any irritation does occur, it is generally short of duration and mild. Rinsing with warm salt water can relieve it.
  • I Understand Use of the product is not recommended for children under 16 or women that are pregnant or breastfeeding.

AFTER CARE: I understand I should avoid eating or drinking any chromogenic substances (i.e. tomato sauce, coffee, red wine and all tobacco substances) for 48 hours after the whitening treatment. I understand it is highly recommended that I, in conjunction with using teeth whitening maintenance products, maintain regular visits to my Oral Hygienist for optimum results.


THE UNDERSIGNED acknowledges that TECHNICIAN has explained the nature of all the above noted treatment of teeth whiteningprocedures including the risks and dangers inherent therein.

I HEREBY CONSENT to performing the above-noted treatment procedures on me and in consideration of their so doing; I hereby release and forever discharge Cosmo Med Spa & Salon,, from all claims, demands, damages, actions or causes of action arising out of the performance of the said treatment procedures, which I, my heirs, executors, administrators or assigns can, shall, or may have. (NO REFUND ON ANY TREATMENT.)