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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 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

shinebykellie@gmail.com

Medical + Dental History

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

Full Name

Address

Phone

Email Address

Date of Birth

How did you hear about Shine by Kellie? If you were referred by a friend, please put their name here.

Are you currently taking any medications? If yes, please list below.

Do you have any allergies? If yes, please list below.

Women: Are you pregnant or breastfeeding?

Have you whitened your teeth before? If so, when and how? (ie. home or in office)

Do you smoke?

Yes

No

Occasionally

Do you have sensitive teeth?

Yes

No

Sometimes

How often do you drink coffee/tea?

daily

a few times a week

once a week

rarely

never

Do you have veneers, crowns, anterior bonding, bridges or dentures in your visible smile?

Yes

No

I don't know

When was your last dental cleaning?

The information I've provided is accurate and true to the best of my knowledge.

Today's Date

Your Signature

If you have any questions or concerns about your teeth, please upload a photo here.

Upload File

Upload supported file (Max 15MB)

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.

What’s your first name?

What’s your email address?

What’s your last name?

What’s your phone number?

I understand that the amount of whitening cannot be predicted or guaranteed. Teeth will not whiten past their genetic whiteness (what you were born with). Yellow or brown teeth with surface stain whiten easier than grey/blue 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 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. Scientific articles have shown that teeth 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 in the to help soothe the gums in addition to the red light therapy. The whitening gel may cause tingling and blanching (whitening) of the gums.These are temporary and not harmful in any way and will disappear in 1-2 days with normal saliva. 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, for the Diamond and Platinum sessions.

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 result.

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/or videos of me, my home or office during my whitening session strictly for the purpose of marketing and display

Yes, I consent to pictures/videos

Yes, I consent to only pictures

Yes, I consent to only videos

Yes, I consent to pictures and/or 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

No

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

Yes

No

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

Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

I am not experiencing the symptoms: fever, cough, sore throat

I haven’t been in close contact with a Covid-19 patient in the last 14 days

I declare that the info I’ve provided is accurate & complete

Your Signature

Date

Thanks for submitting!

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