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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

CONSENT FORM & SESSION SELECTIONS
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).
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.
I have read and understand this consent form, and understand the risks and benefits explained in it.
I have had opportunities to ask questions about the procedure. And my questions were answered to satisfaction.

Now for the fun stuff!

Choose your luxuries for your whitening session!

Please choose your whitening session:
Please choose ONE of the following flavours of lip balm for your session:
Please choose ONE of the following colours of bamboo toothbrushes for your session:
Please choose ONE of the following flavours of floss for your session:
If you are interested in adding any product(s) to your whiteing session, please check which one(s) you are interested in:

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

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