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Mobile Teeth Whitening

289-983-5188

shinebykellie@gmail.com

black white smile.jpg

Hello & Thank you for choosing shine by kellie for your professional teeth whitening needs!

Please fill out all forms below 48 hours prior to your appointment time.

All forms must be submitted online BEFORE your scheduled appointment.

IF THIS IS NOT COMPLETED 24 HOURS PRIOR TO YOUR APPOINTMENT IT MAY RESULT IN CANCELLATIONS OR DELAYS IN YOUR APPOINTMENT.

THANK YOU FOR YOUR CO-OPERATION.

Please see FAQ for any questions you may have.

Be sure to check out the Before and After Care.

Burlington, ON

shinebykellie@gmail.com

CONSENT FORM & SESSION SELECTIONS

First name

Last name

Email

Phone

I understand that the amount of whitening cannot be predicated or guaranteed. Teeth will not whiten past their genetic whiteness. Yellow or brown toned teeth with surface stain whiten easier than grey/blue tone teeth. Spotted teeth can also be difficult to whiten. It may be possible to remove light staining on fillings, crowns and veneers, but they will not whiten past their original colour.

I understand that our whitening system uses hybrid gels and LED blue + red light that enhances their gel components. This process may or may not require additional whitening in order to achieve your desired results.

I understand that our whitening gels have adjusted pH and conditioners to reduce teeth and gum sensitivity. However, all teeth react differently. In the unlikelihood that sensitivity does occur, it may be present for 1-2 days. Whitening is safe and effective. It does not change the structure of your teeth, it simply helps to achieve a whiter, brighter look.

I understand that our whitening gels have conditioners and moisturizers to help soothe the gums in addition to the red light therapy. The whitening gel my cause tingling and blanching (whitening) of the gums. These are temporary and not harmful and will disappear in 1-2 days. Vitamin E oil can be applied to these areas if needed. Everyone's gums can react differently to the gel. Note: A barrier will be applied to protect the gums.

I understand that my teeth may relapse and revert back to their original colour.This is normal and may require additional whitening sessions in order to achieve your desired results.

I agree to the use of my before and after photo strictly for the purpose of marketing and display. (only pictures of your teeth will be used). *

Yes, I consent

No, I decline

I agree to the use of pictures and/o videos of me, my home or office during my whitening session strictly for the purpose of marketing and display. *

Yes, I consent to pictures and videos

Yes, I consent to only pictures.

Yes, I consent to only videos.

Yes, I consent to pictures and videos but do not want my face shown.

No, I decline pictures/videos

I have read and understand this consent form, and understand the risks and benefits explained in it. *

Yes

Choice 2

I have had opportunities to ask questions about the procedure. And my questions were answered to satisfaction. *

Yes

No

I consent to treatment and I assume responsibility for the risks mentioned above.

Now for the fun stuff!

Choose your luxuries for your whitening session!

Please choose your whitening session: *

Platinum Whitening Session

Diamond Whitening Session

Group or Bridal

Please choose ONE of the following flavours of lip balm for your session: *

Vanilla Bean

Vegan Coconut Beach

Vegan Unicorn Dust (berry flavoured)

None, I don't want any

Please choose ONE of the following colours of bamboo toothbrushes for your session: *

Sunny Pink

Soft Lilac

Glacier Blue

Minty Green

Charcoal

None, I don't want any

Please choose ONE of the following flavours of floss for your session: *

Delicious Mint

Fresh Coconut

Pure Strawberry

Cara Cara Orange

None, I don't want any

If you are interested in adding any product(s) to your whiteing session, please check which one(s) you are interested in:

Professional Home LED Whitening Kit

Whitening Extender Pen

Metal Straw Kit

Bamboo Toothbrush

Lip Balm

Thanks for submitting!
We look forward to making your smile SHINE!

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