Whitening Information

This is an example of our consent form that we give patients before we start whitening treatment.

Home Bleaching Instructions and Consent Form


We are planning to whiten your teeth using carbamide peroxide solution. Please read the following instructions carefully.
The active ingredient is carbamide peroxide in a glycerine base. If you know of any allergy or are aware of an adverse reaction to this ingredient, please do not proceed with this treatment.

As with any treatment there are benefits and risks. The benefit is that teeth can be whitened fairly quickly in a simple manner. The risk involves the continued use of the peroxide solution for an extended period of time. Research indicates that using peroxide to bleach teeth is safe. There is new research indicating the safety for use on the soft tissues (gingiva, cheek, tongue, throat). The long-term effects are as yet unknown. Although the extent of the risk is unknown, acceptance of treatment means acceptance of risk.

This type of whitening treatment has been done for some patients for over 40 years. During that time, nobody has needed a root canal or damaged a tooth following home bleaching treatment.

The amount of whitening varies with the individual. Most patients achieve a change within 2-5 weeks. try and minimise your intake of tea, coffee, or red wine or eat berries or curries during treatment, and for atleast 1 week after treatment . You may use the tooth paste supplied with the kit to clean your teeth during treatment.

It is advisable not to smoke, or reduce smoking during the course of bleaching treatment, for at least 1-2 weeks.

Sensitivity may result after a few days. This is usually slight and temporary. If this should occur, refrain from using the bleaching treatment for 1 day or apply the soothing gel in to the tray that you will be given.

Do not use the bleaching treatment if you are pregnant. There have been no adverse reactions, but long-term clinical effects are unknown.
Wear the tray loaded with whitening gel  for 1 hour per day.
Some teeth do not bleach evenly particularly around gum recession on the premolar teeth. The enamel bleaches well but the exposed dentine does not bleach as well.

When the treatment is completed, please keep the trays so that they can be used for a top-up maintenance treatment. This can be done once or twice a month, as required, to maintain the tooth whitening. It all depends on how quickly the patients stains their teeth again. 

I have read the above information and agree to return for a review appointment 2 weeks after treatment begins and at any recommended time afterwards. I have read and received a copy of this information sheet. I consent to treatment and assume the risks described above.
I consent to photographs being taken. I understand that they may be used for documentation and for illustration of my treatment.