Terms and conditions for teeth whitening offers

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1 Terms and conditions for teeth whitening offers 1. You can only make an informed decision once you have read and understood all the information provided by us in the following documents: a. Terms and conditions b. Information and instructions for home teeth whitening c. Consent form 2. We may refuse to perform teeth whitening if you are not suitable. This could be the case if you: a. are pregnant, b. have dental decay, c. suffer from certain medical conditions, d. have active gum disease e. have multiple crowns f. have large fillings on the teeth you want to whiten g. have a strong gag reflex which prevents the taking of dental impressions h. are under the age of 18 i. do not consent to a dental examination to check that your teeth and mouth are healthy and suitable for dental whitening 3. The offers are promotional and time limited until 31/03/2016 and subject to current capacity. 4. The practice reserves the right to withdraw the offers at any time without prior notification. 5. You are welcome to ask any questions over the phone or to come in and make enquiries in person. In some cases, we could advise whether you are not suitable for teeth whitening without having an examination. In these circumstances, as long as you do not book an appointment with the dentist, there will be no charges. 6. Teeth whitening should only be done on healthy teeth without cavities or faulty fillings. As professionals it is our duty to check that our patient s teeth and gums are healthy enough to undergo the whitening procedure. Any further investigations/procedures that you may need or want will be discussed with you for your approval before anything else is done. 7. There are two types of assessments that need to be done. a. A dental examination to check that your teeth and gums are healthy. (No dental decay, broken fillings, infections) The examination can be done privately or under the NHS, according to your choice. The cost of the examination is If you decide to make use of one of our whitening offers, the offer price quoted will cover your dental examination. b. A cosmetic assessment of the colour of your teeth and restorations (crowns, fillings). This is necessary so we can inform you of how successful the whitening procedure is likely to be. The cost of the cosmetic assessment is covered by the offers for teeth whitening. c. If you decide to book an appointment for a dental examination, a cosmetic teeth whitening assessment and dental impressions for whitening trays, we will ask you for payment in full for the procedure or procedures that you have requested and to which you have consented. 8. Cancellations, changes of treatment plan and refunds. a. Cancellations You can cancel any booked appointment with more than 24 hours notice. There are no fees for cancellations with more than 24 hours notice or for cancellations due to medical emergencies. Any cancellations with less than 24 hours notice are late cancellations. We reserve the right to charge for late cancellations. The charge for late cancellations is 35. b. Changes of treatment plans. You can change your mind and choose to stop or postpone all or some of the treatment. We will inform you if we think you need other treatment. We will give you an estimate for the cost of such treatment and we will only carry it out with your consent. c. Refunds. We cannot refund treatment which has already been provided or for which we have incurred laboratory costs. Teeth whitening works very well on most teeth but the result depends on the starting colour of the teeth, the presence of stains and dark patches, existing restorations and to a certain extent the patient s expectations. All these issues will be discussed with you before

2 you start the whitening procedure. We can promise you that we will do our work to a high standard and that the products you a receiving from us are working at the time of delivery but we cannot guarantee that home bleaching alone may be enough to enhance the cosmetic appearance of the teeth to a level which is only achievable by more complex procedures. d. Examples: You decide to book an appointment with the dentist for the dental examination, cosmetic assessment and impressions for whitening trays. The examination reveals that you have dental problems and you are not suitable for bleaching. A charge will then only be made for the examination. This charge is and is non-refundable. No other charges will apply until the problems have been fixed and you decide to continue with the whitening procedure. You decide to book an appointment with the dentist for the dental examination, cosmetic assessment and impressions for whitening trays. The examination shows no dental problems and you decide to proceed with having impressions taken to provide whitening trays. Once you have asked us to take impressions and if the impressions have been sent to the dental technician for the manufacturing of the bleaching trays, the charge will be in accordance with the offer you have chosen and no refunds will be given once the impressions are on the way to the technician. You ask us to do the teeth whitening but not the examination. Unless you have been examined by us (since we cannot take responsibility for dental examinations done at other practices) in the last 6 months, we will refuse to book you in for the teeth whitening procedure. 9. The offer is restricted to one appointment. Further appointments may incur additional charges. You are welcome to request further information before you decide if you want to make use of our offers. Please call or the practice for full terms and conditions. Contact details are available below. 34 High Street, Ipswich, IP1 3QJ Tel: lighthousedental@btconnect.com I have read and understood the terms and conditions Date Name Signature

3 Teeth whitening instructions, information and consent Please read the following instructions carefully. You should not have teeth whitening if you are allergic to any of the ingredients in the bleaching/teeth whitening gel or tray material. The bleaching gel is Carbamide Peroxide and the trays are made of silicone. You should not use the try-in gel if you are allergic to chlorhexidine/ Corsodyl Furthermore, you should not bleach your teeth if you: a. are pregnant, b. have dental decay, c. are under the age of 18 d. have active gum disease You should discuss your case with the dentist if you have: e. multiple crowns or large fillings on teeth which you intend to whiten f. have a strong gag reflex which prevents the taking of dental impressions g. suffer from certain medical conditions which may be incompatible with dental whitening The teeth whitening gel contains Carbamide Peroxide in glycerine base. Our teeth whitening gels have been used by our dentists on their own teeth. As with any treatment, there are benefits and risks. The benefit is that teeth can be whitened quite quickly and simply. The risk is associated with continued use of the peroxide solution for extended periods (i.e. years). Research indicates that using Carbamide Peroxide gels in concentrations as provided by us and in accordance with our recommended procedure for home teeth whitening is safe for the hard tissues of the teeth. Research directed at the safety of its use on soft tissues (i.e. gums/cheeks/tongue/throat) indicates that the long-term effects are yet unknown. The effectiveness of tooth whitening varies with each individual though most patients will achieve a change after 2-5 weeks. For the duration of treatment, you are advised to reduce consumption of intensely coloured foods and drinks such as red wine, dark tea, strongly coloured fruits, coffee, etc. Some experts suggest avoiding any food that would stain a white shirt. Dental bleaching is an effective method to whiten your teeth. Due to variations between individuals such as starting shade, frequency of use and diet, the effect may be reached faster in some individuals and slower in others. Although most types of teeth will bleach very well, a few may not become as white as expected. These factors are outside our control; therefore, we cannot guarantee a certain shade. Fillings, crowns, veneers or other restorations do not bleach well. You may need to change some fillings to match the teeth after the whitening procedure has finished. Some patients may experience sensitivity after a few days this is quite common and will usually be slight and temporary. If this does occur, take a break from using the bleaching treatment for a day. After a day or two you can restart the procedure as recommended. If sensitivity persists, please contact your dentist for further advice. Some teeth with very dark patches or dark exposed dentine do not bleach evenly. They may need a longer bleaching time. Discuss any problems with your dentist.

4 This treatment should not be undertaken if you are pregnant or think you may be pregnant. Whilst no adverse reactions have been reported, the long term clinical effects are unknown. The gel used may cause irritation if it comes into prolonged contact with your gums, or skin. If this occurs, wash the affected area thoroughly with water. Avoid getting gel into the eyes. When you have achieved the whiteness you require, please keep your bleaching trays so they can be used for top-up treatments. Some patients may never need to repeat the process, however if you feel your teeth are becoming stained again the treatment can be repeated for a night or two. THE KIT You should have Custom made whitening trays Bleaching gel syringes Spare syringe with Corsodyl gel for practicing the application of gel into the bleaching trays PROCEDURE How to apply whitening gel into the trays Brush and floss your teeth thoroughly. Practice gel application using Corsodyl Gel To learn how much gel you should put into the whitening trays, use the provided Corsody gel syringe. Apply the gel at the bottom of each tooth compartment in the tray to about one third of the height of each tooth. Put the tray in the mouth. Ideally, no gel should run over the edge of the tray onto your gums. Practice this step until you get it right. Apply bleaching gel in trays and put them on the teeth Place one dose of bleaching gel into each whitening tray by injecting a small amount of gel in each tooth compartment of the whitening trays. We find that filling each tooth compartment to approximately 1/3 of the volume should be just about right. Be careful not to overfill the trays. Secure the tray(s) into your mouth ensuring that they are completely seated. There should be no visible signs of gel displaced onto the gums when the trays are secured. If you are using Pola Night, you should preferably keep the trays in for minutes, but you can also keep them in overnight. (Keeping them in overnight will not give you faster or better teeth whitening) If you notice small amounts of bleaching gel seeping out of the trays onto the gums, wipe the excess off with a wet cotton wool bud, then rinse your mouth once or twice very gently to remove the excess gel. If you get a lot of gel seeping into the mouth, take the trays off and rinse your mouth thoroughly with lukewarm water until you have rinsed out all the gel. Try practising with Corsodyl gel a few more times before you use the bleaching gel again. To achieve the quickest result, treatment should be uninterrupted, however, if you do skip a session, continue where you left and the gel should catch up and continue to bleach. After treatment, remove the trays and rinse your mouth out with lukewarm water thoroughly. You can also brush away residual gel. Rinse the trays with cold water, brushing if necessary to remove any residual gel. Store the trays in the case provided in a dry place away from direct heat or sunlight. Do not refrigerate the trays. The bleaching gel syringes should be kept refrigerated. After treatment, avoid citrus foods and juices as these may cause sensitivity as they change the acidity of your saliva and may also cause irritation or slow down the whitening process.

5 If your teeth become very sensitive, take a break for one or two days and re-start the treatment later. When applying the trays on the teeth, sometimes, small amounts of bleaching gel can be extruded around the gum line. This may cause the gums to become white. If you notice that the gel is leaking outside the tray and onto the gums, rinse the mouth gently with water and keep the tray in. If you notice that the gel leaks out of the trays onto the gums on more than one or two teeth, you are probably overfilling the trays. Go back to the practice step and try the trays in with some Corsodyl gel. If the gel makes your gums itchy or stingy, take them out, rinse the gel off the teeth and either try again using less gel or take a 24-hour break before trying again. If you have any problems or questions, please call the practice for advice DO NOT: Use this treatment if you are, or may be pregnant or if you are breastfeeding. Eat, drink or smoke whilst wearing your bleaching trays. Do not: Ever use any other products (household or whitening) to whiten your teeth. Polanight information Whitening agent 16% Carbamide peroxide Time for applications minutes to overnight Fluoride releasing The addition of fluoride remineralises the tooth surface assisting in reducing post-operative sensitivity. Contains desensitising agent Neutral ph The Pola Day and Pola Night gels contain a desensitising agent which acts on the nerve endings and desensitises them at the pulp-dentin border, in turn minimising sensitivity and maximising patient comfort. Pola Day and Pola Night s neutral ph ensures the full release of the peroxide without jeopardising patient comfort. PATIENT CONSENT : I have read and understand the above information and have received a copy of the instruction sheet for home teeth bleaching. I consent to the treatment proposed and confirm my understanding and acceptance of the associated risks outlined to me. I consent to photographs being taken to document and illustrate the results of my treatment. Date Name Signature.