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Minty Teeth Whitening Consent Form


Teeth Whitening Expectations 

Safely removes stains caused by foods, beverages, tobacco, medicine, and aging. 


  • When whitening, you may feel a slight tingling.

  • Products will not damage existing dental work.

  • Products will remove stains from existing dental work but will not whiten them beyond their original color.

  • White spots may appear more prevalent directly after whitening, but the contrast will lessen within 24 hours. 

  • Everyone’s teeth respond differently and have their own natural “stop” point for whitening results. 

  • Teeth may feel temporarily sensitive; sensitivity is typically minor and gone within 24 hours.

  • You may experience temporary gum irritation, which is more prevalent in clients that have brush abrasion from brushing teeth within 4 hours prior to whitening. 


To maintain healthy teeth and gums, it is recommended that you visit your dentist on a regular basis. If you have allergies or reactions to peroxide or glycerin, teeth whitening is not recommended. If you have diabetes, heart conditions, pregnant, and/or currently breastfeeding you may want to consult with your doctor prior to using whitening products. Any existing mouth sores may feel temporary irritation during and/or whitening. 

*Satisfaction is guaranteed at the time of service; no refunds will be given after payment of services.

In consideration of the services provided and other good and valuable consideration, the sufficiency of which is acknowledged by signature, Customer hereby releases forever, and discharges these Teeth Whitening services and any other entity offering any of these services rendered and its employees, distributors and/or wholesaler their heirs, executors, administrators, successors, and assigns of and from all action, which Customer, his/her heirs, executors, administrators and assigns or any of them hereafter can, shall or may have for any reason whatsoever, including all actions, causes of action, damages, claims, and demands arising out of service or serviced offered.

*By signing below you acknowledge that the Laser teeth whitening process (also known as light accelerated whitening) is a self-administered process and that you have read and hereby acknowledge all information within. 

Thank you!

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