CLIENT CONSENT/MEDICAL FORM
TEETH WHITENING SERVICE
Name
*
First Name
Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health and Dental Information
Toothpaste Brand
*
Are you using Dental floss in cleaning your teeth?
*
Please Select
Yes
No
Are you using braces?
*
Please Select
Yes
No
Do you have tooth filling?
*
Please Select
Yes
No
Do you have any known tooth decay or broken teeth?
*
Please Select
Yes
No
Do you have any allergies?
*
If yes, then please specify it on the field above.
Are you currently taking any medications?
*
If yes, then please specify it on the field above.
Do you have any medical conditions that we should be aware of? (Communicable disease, cardiovascular problems, diabetes, etc.)
*
If yes, then please specify it on the field above.
Waiver and Consent
Type a question
*
I authorize Arch Angels NYC/NJ to perform this procedure to me. The artist explained the nature of the treatment and how it will help me.
I allow Arch Angels NYC/NJ to administer teeth whitening gel and understands the side effects given to me.
I understand the risk and complications if I do not follow the instructions given to me after the procedure.
I release Arch Angels NYC/NJ for any responsibility in case of an accident, illness, or injury.
I acknowledge that all information I provided int his form is true and accurate.
Signature of the Patient
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit
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