top of page

Please fill out the following form.

Have you ever done teeth whitening?
No
Yes
Do you have known receding gum lines?
No
Yes

I understand that although approximately 98% of clients see noticeable results after one visit, results may vary depending on existing staining, enamel condition, and genetic factors. The teeth whitening technician at Glitz Spray Tanning will provide guidance to help me achieve the best possible outcome.

I acknowledge that in very rare cases (less than 1% of clients), some individuals may be unable to continue with the treatment due to sensitivity or other factors. I understand that the cost of the disposable mouth guard and the whitening product used during the session is non-refundable and will be charged regardless of treatment completion. Our whitening formula contains desensitizing agents, so these reactions are extremely uncommon.

I confirm that I have had the opportunity to ask questions about the procedure and that all my questions have been answered to my satisfaction. I understand the information provided and consent to proceed with the teeth whitening treatment.

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Date
Month
Day
Year
bottom of page