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

Please fill out all 3 forms below 24 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 COOPERATION.

Please see FAQ for any questions you may have.

Be sure to check out the Before and After Care.

Burlington, ON

Medical + Dental History 

Please fill out the medical + dental history upon booking your appointment. 

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Do you smoke?
Do you have sensitive teeth?
How often do you drink coffee/tea?
Do you have veneers, crowns, anterior bonding, bridges or dentures in your visible smile?
Upload File

Thanks for submitting!

Consent Form
Please note this form has 2 pages. Please select next at the bottom to complete your session choices.
The sumbit button will appear after you have completed the second page of this form. 

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/or 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 my satisfaction

Covid-19 Health Declaration

How are you feeling today?

Thanks for submitting!