Informed Consent Form

Teeth Whitening Treatment

1. PATIENT DETAILS

Patient Name

Age

Gender

Male Female

Contact Number

Email (optional)

Address

Medical History Reviewed

Yes No

If yes, attach / mention details

Allergies (if any)

Current Medications

2. PROCEDURE

Treatment / Procedure

Teeth Whitening Treatment

Tooth / Teeth Involved

Brief Explanation

Teeth whitening is a cosmetic procedure that uses a whitening gel/solution to lighten the shade of your teeth and remove stains or discoloration. It does not work on crowns, veneers, fillings or other dental restorations.

3. BENEFITS

Improves the appearance of teeth.
Removes stains caused by food, drinks, smoking and aging.
Boosts self-confidence and smile aesthetics.
Non-invasive and safe when performed by a dental professional.
Provides a brighter, younger-looking smile.

4. RISKS & COMPLICATIONS

Temporary tooth sensitivity (common).
Gum irritation or sensitivity.
Temporary off shade or uneven results.
Whitening results vary from person to person.
Allergic reaction to whitening gel (rare).
Over-whitening may cause increased sensitivity.
Results are not permanent; touch-up treatments may be needed.

5. ALTERNATIVES

Alternative Treatment Options: Professional cleaning, polishing, dental bonding, veneers, crowns.

Option of No Treatment: Stains and discoloration will remain, which may affect the appearance of your smile.

Consequences of Delaying / Refusing Treatment: No change in the color of teeth; staining may increase over time.

6. PATIENT ACKNOWLEDGEMENT

I have been informed about the nature of the procedure, its benefits, risks, possible complications, alternatives and the consequences of not having the treatment. I have had the opportunity to ask questions and all my questions have been answered to my satisfaction.

7. CONSENT

I voluntarily consent to undergo the above-mentioned procedure.

Patient / Guardian Signature

(sign after printing)

Dentist Signature

(sign after printing)

Witness Signature (if applicable)

(sign after printing)

FOR CLINIC USE — PATIENT COPY

اردو میں رضامندی کا بیان (Urdu Consent Statement)

ڈاکٹر نے مجھے میرے دانتوں کے علاج کے طریقہ کار، ممکنہ خطرات، فوائد اور متبادل علاج کے بارے میں مکمل طور پر بتایا ہے۔

تمام سوالات کے جوابات سے میں مطمئن ہوں اور اپنی مرضی سے اس علاج کے لیے رضامند ہوں۔

This document is a record of informed consent and does not replace professional legal advice. Retain a signed copy in the patient’s file.