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ZOOM! In-Office Tooth Whitening Consent Form Mobile App

Complete the In-Office Tooth Whitening Consent Form quickly on an iPhone, iPad, or Android device. This dental whitening tool provides information on: the cosmetic dentistry procedure and the dental practice that will perform the treatment; the risks involved, including tooth sensitivity, soft tissue, and root resorption; and costs of this dental treatment. You can also capture the signature of your patient. This is especially beneficial if you need to get consent from a legal guardian. Each consent form is saved in the GoCanvas Cloud and can be shared as a PDF.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the ZOOM! In-Office Tooth Whitening Consent Form Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

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    DESCRIPTION OF THE PROCEDURE

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    ZOOM!

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    ALTERNATIVE TREATMENTS

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    I understand that I may decide not to have the ZOOM treatment at all.

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    COST

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    I understand that the cost of my ZOOM treatment is determined by my dentist.

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    RISKS OF TREATMENT

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    Tooth Sensitivity/Pain- During the first 24 hours after ZOOM treatment, many patients can experie...

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    Gum/Lip/Cheek Inflammation- Whitening may cause inflammation of your gums, lips or cheek margins.

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    Dry, Chapped Lips Cavities or Leaking Fillings- Most dental whitening is indicated for the outsid...

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    Cervical Abrasion/Erosion- These are conditions which affect the roots of the teeth when the gums...

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    Root Resorption-This is a condition where the root of the tooth starts to dissolve either from th...

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    Relapse- After the Zoom treatment, it is natural for teeth that underwent to ZOOM treatment to re...

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    I understand that after all treatment; I will be required to refrain from consuming any substance...

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    By signing this document in the space provided I indicate that I have read and understand the ent...

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    Date

  • Ico signature

    Doctor Signature

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    Witness Signature

  • ...and More!

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