Consent form

Teeth whitening

Read this before your appointment, and ask us about anything you don't understand — we'll be pleased to explain. If your dentist has asked you to complete it, you can sign at the bottom.

Southside Dental Toowoomba Shop 17, 445 Hume Street
Kearneys Spring QLD 4350
(07) 4635 1444
1

What it involves

Pola Office+ whitening lightens the colour of your teeth using a 37.5% hydrogen peroxide gel together with a purpose-built LED lamp. Using the gel and the lamp in combination is what produces the maximum result in the shortest time.

  • Before and after, the shade of your teeth is assessed against the Vita Pan Classic shade guide and recorded photographically.
  • A plastic retractor holds your mouth open and keeps your lips and tongue away from the teeth. Lip balm is applied as needed.
  • Your lips, cheeks, gums and tongue are covered so they're not exposed to the gel or the light.
  • The gel is applied and the teeth are exposed to the lamp for three or four fifteen-minute sessions, depending on what your clinician recommends. You wear protective glasses throughout.
  • Afterwards the retractor, gel and coverings are all removed.

It's a safe procedure carried out by a qualified clinician. Whitening may not be appropriate for people with oral symptoms of certain conditions, which is part of what we check first.

Have a scale and clean first. Bleeding or unhealthy gums stop the protective barrier sticking properly, which makes gum inflammation afterwards more likely, and calculus deposits obscure the teeth. A professional clean beforehand is recommended.

2

Risks and possible complications

  • Tooth sensitivity or pain in the first 48 hours. This is normal and can be worse in susceptible people. Ibuprofen or paracetamol usually settles it, and it normally passes within 24 hours.
  • Sensitivity that's stronger or lasts longer if you already have sensitive teeth, recession exposing root surfaces, exposed dentine, untreated decay, cracked teeth, abfractions, open cavities or leaking fillings — all of which let more gel penetrate the tooth.
  • Inflammation of the gums, lips or cheeks, usually lasting a day or two. Your clinician can generally see it straight after the procedure and will advise what to do. Keeping your face still and not talking during the procedure significantly reduces the chance of it.
  • Dry or chapped lips, from having your mouth held open by the retractor for three or four fifteen-minute sessions. Lip balm or pawpaw ointment treats it.
  • Cervical abrasion or erosion areas — grooves, notches or depressions on the roots that look darker because they lack enamel. Even if they aren't sensitive now, they let the gel penetrate and cause sensitivity. We cover these before starting.
  • Existing fillings, crowns and veneers won't lighten. Whitening only changes natural tooth structure, not artificial teeth, crowns, veneers, porcelain or composite filling material.
  • Colour relapse. The shade naturally regresses somewhat over time. It should be gradual, but tea, coffee, red wine and tobacco all accelerate it.
3

Straight after your appointment

For 24 hours, until the colour stabilises, avoid strongly coloured food and drink — the rule of thumb is anything that would stain a white shirt — and don't smoke.

If relapse becomes noticeable later, it's treated by wearing take-home whitening trays, which are supplied as part of the Pola whitening package.

4

Your alternatives

  • Take-home whitening with custom trays, worn over a period we'd guide you through.
  • A scale and clean alone, which removes surface staining without changing the underlying shade.
  • Veneers or composite bonding, where the discolouration is internal and won't respond to whitening.
  • Doing nothing — whitening is entirely elective.
5

Looking after it — your part

Your teeth need daily care at home and a check-up every 3 to 6 months, which isn't included in the cost of whitening.

  • Follow all the instructions you're given.
  • Clean your teeth and gums thoroughly, as instructed.
  • Come in for examinations and cleans every 3 to 6 months as your clinician advises. There's a fee for these visits.
  • Tell us straight away if you notice a problem.
6

Your details

Full name

Date of birth

Mobile

Starting shade

Treating clinician

Total cost

7

Your acknowledgement

  • I have been informed of the reasons for whitening, the risks, the alternatives and the maintenance needed.
  • I understand the procedure uses a 37.5% hydrogen peroxide gel with an LED lamp, over three or four fifteen-minute sessions.
  • I understand sensitivity or pain in the first 48 hours is normal, and may be stronger or last longer if I have existing sensitivity, recession, untreated decay, cracked teeth or leaking fillings.
  • I understand my gums, lips or cheeks may be temporarily inflamed, and my lips may be dry or chapped afterwards.
  • I understand whitening does not lighten fillings, crowns, veneers or any artificial tooth material.
  • I understand the colour will relapse gradually over time, faster with tea, coffee, red wine and tobacco, and that take-home trays supplied with the package are used to top it up.
  • I understand I should avoid strongly coloured food and drink, and not smoke, for 24 hours afterwards.
  • I understand a scale and clean beforehand is recommended, and that whitening goes on healthy gums and teeth.
  • I agree to follow the home care instructions, and to attend for regular examinations and cleans as instructed.
  • I have given an accurate report of my physical and mental health and medical history, including any previous allergic or unusual reactions.
  • I understand that no guarantee or assurance has been given about the final shade, and that results vary from person to person.
  • I have read the information above and had the chance to ask questions.
  • The costs have been explained to me, and I can ask for a written quote before treatment starts.
  • I understand I can change my mind at any time before treatment starts.
  • I understand my clinician will go through this with me and confirm my consent in person on the day.

Signature

Date

This form records that you have read and understood the information above. It is not consent to proceed — your clinician confirms consent with you in person before treatment begins, and you can withdraw at any time.

Before and after

How to prepare is on our pre-appointment page, and there's more about your options on our whitening page. Any questions before the day, call 07 4635 1444.