Organically White Terms & Conditions
Organically White requires advance notice of 24 hours to cancel or reschedule any appointment. In the event you are unable to provide us with at least 24 hours notice, we will assess you a $50 no-show fee. We are happy to store the $50 no-show fee as a credit on your account and this may be redeemed for future rescheduled appointments. The $50 no-show invoice will be due within 7 days of the date the invoice was created, and if left unpaid, we reserve the right to pursue other legal means of collections activity.
If you are unsatisfied in any way, please email firstname.lastname@example.org with your name, appointment time and why you are unsatisfied. We will strive to do our best to make sure you are as satisfied as possible. Organically White does not guarantee any refunds for our teeth whitening services or products.
I have been given this information in order that I may be able to make an informed decision about undergoing a teeth whitening procedure. I am able to take as much time as I need to come to a decision whether or not to sign this informed consent form. I am free to ask any questions to Organically White staff about any procedure before I consent to undergoing any procedure.
I understand that I will undergo up to four 20 minute teeth whitening mini-sessions to achieve desired results. The teeth whitening treatment is designed to lighten the color of my teeth and safely whiten stains caused by foods, beverages, tobacco and medicine. Organically White uses a combination of a hydrogen peroxide gel and a specially designed FDA approved LED light to achieve ideal results.
I understand that I am not being treated by a dentist, my technician has no dental qualifications and that my teeth are not being examined for health, cavities, etc. I am aware that I should be examined by a dentist prior to treatment. I have been advised by my dentist that I currently have healthy teeth and gums. Organically White products will not damage existing dental work. Organically White can whiten stains from existing dental work but will not whiten them beyond their original color.
If I am pregnant or nursing I have consulted with my OBYN and have been given the ok to proceed with whitening.
I have been given this information in order that I may be able to make an informed decision about undergoing a teeth whitening procedure. I am able to take as much time as I need to come to a decision whether or not to sign this informed consent form. I am free to ask any questions about any procedure before I consent to undergoing any procedure.
I understand when whitening that I may feel a slight tingling on my gums and/or teeth. White spots on my teeth may appear directly after whitening, but the contrast of color will lessen within 24 hours. I understand that my teeth may feel temporarily sensitive; although sensitivity is typically minor and gone within 24 hours. I may choose to take an Advil or other basic pain reliever to help with relief of sensitivity. I may experience temporary gum irritation, which is more prevalent in clients that have brush abrasion from brushing teeth within 4 hours prior to whitening.
I understand that significant whitening can be achieved in the vast majority of cases, but that results cannot be guaranteed. Everyone’s teeth respond differently and have their own natural stopping point for whitening results. -Dark yellow or yellow-brown teeth tend to have better results than gray or bluish-gray teeth. I understand that multi-colored teeth, especially if stained due to tetracycline, do not whiten very well.
I understand that when done properly, the whitening will not harm my teeth, gums or soft tissues. However, like any other treatment, I understand that it has some inherent risks and limitations.
I understand possible side effects can include but are not limited to: allergic reaction to the gel solution, dry/chapped lips, tooth sensitivity and irritation of the soft tissues (particularly the gums). In some cases, direct exposure to UV lighting or LED lighting can trigger a cold sore outbreak, typically if I am already prone to cold sores.
I have read and understand the pre and post treatment instructions. I agree to follow these instructions carefully. I understand that compliance with recommended pre and post procedure guidelines are crucial for healing, prevention of side effects and complications as listed above. The nature and purpose of the treatment have been explained to me. I have read and understand this agreement. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement.
I release Organically White, staff, and all specific technicians from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age and/or I am a competent adult parent or legal guardian of the minor listed below. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors and assigns.
I grant permission to Organically White for the use of my photograph(s), or electronic media images, in any presentation of any kind and/ or any of Organically White’s social media outlets. I understand that I may revoke this authorization at any time by notifying Organically White in writing. The revocation will not affect any actions taken before the receipt of this written notification. Images will be stored in a secure location and only authorized staff will have access to them. They will be kept as long as they are relevant and after that time destroyed or archived.