Teeth Whitening Waiver | Glitz Spray Tanning

Please fill out the following form.

First name

Last name

Have you ever done teeth whitening?

No

Yes

Do you have known receding gum lines?

No

Yes

My last dental visit was

Within a year

Over a year

Even though 98% of clients leave with a result after one visit, I do acknowledge that the results of teeth whitening depend on existing staining and genetic factors. The teeth whitening technician at Glitz Spray Tanning will provide guidance to help me achieve optimal results.

By signing below, I consent to the teeth whitening treatment provided by Glitz Spray Tanning.

Signature

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Date

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Day

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