Teeth Whitening Intake Form ContactName(Required) First Last Email(Required) Phone(Required)Phone Type(Required) Home Mobile Work Other It's OK to text me! Yes No Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code DaVinci Teeth Whitening Expectations: DaVinci Teeth Whitening safely removes stains caused by foods, beverages, tobacco, medicine, and aging. For the ultimate whitening effect on your teeth, you have the option to preform up to 3 whitening sessions at this time. DaVinci products will not damage existing dental work. DaVinci products will remove stains from existing dental work but will not whiten them beyond their original color. White spots may appear more prevalent directly after whitening, but the contrast will lessen within 24 hours. Everyone’s teeth respond differently and have their own natural “stop” point for whitening results. Teeth may feel temporary sensitivity; sensitivity is typically minor and gone within 24 hours. You may choose to purchase a desensitizing treatment with your whitening. You may experience temporary gum irritation, which is more prevalent in clients that have brush abrasion from brushing teeth within 4 hours prior to whitening. DaVinci Product: DaVinci products offers enamel strengthening qualities. It is organic plant and mineral based containing NO animal by-products. The active ingredient is Food Grade Hydrogen Peroxide. Recommendations: To maintain healthy teeth and gums, it is recommended that you visit your dentist on a regular basis. If you have allergies or reactions to peroxide or glycerin, teeth whitening is not recommended. If you have diabetes, heart conditions, are pregnant, and/or currently breast feeding you may want to consult with your doctor prior to using whitening products. Ask your representative for a list of ingredients if you have concerns. Any existing mouth sores may feel temporary irritation during and/or after whitening.How did you hear about DaVinci Teeth Whitening? Agreement(Required) I accept the following statements.Satisfaction is guaranteed at the time of service, no refunds will be given after payment of services which is deemed satisfaction of results. In consideration of the services provided and other good and valuable consideration, the receipt and sufficiency of which is acknowledged by signature, Customer hereby releases forever, and discharges DaVinci Teeth Whitening, LLC and any other entity offering any of these services rendered and its employees, distributors and/or wholesaler their heirs, executors, administrators, successors, and assigns of and from all action, which Customer, his/her heirs, executors, administrators and assigns or any of them hereafter can, shall or may have for any reason whatsoever, including but not limited to all actions, causes of action, damages, claims and demands arising out of service or services offered.Consent(Required) I agree to the notice.By signing below you acknowledge that the DaVinci Laser teeth whitening process (also known as light accelerated whitening) is a self administered process and that you have read and hereby acknowledge all information within.Signature(Required)NameThis field is for validation purposes and should be left unchanged.