STANDARD INFORMED CONSENT

Dentist: Dr. Robert A. Milner and Associates

Patient: _________________________________________________________

Address: _________________________________________________________

Phone: ___________________________________________________________

Home “teeth bleaching techniques” are designed to lighten dark or stained teeth. Patients apply an oxygenating or peroxide type material at home using one of several techniques. While these materials have been used for this process since 1989 and appear safe, infrequent side effects can occur. Tooth sensitivity or tingling is the most common side effect. Soft tissue irritation can also occur. If a patient experiences these or other adverse symptons, he/she should stop using the bleaching material, and consult their treating dentist. If the patient has any known chemical sensitivity or allergic reactions to ingredients such as flavorings, color additives, etc. please be sure to inform your dental professional.

Patients should also understand that the amount of bleaching and its duration might vary. While most teeth lighten to the extent desired, some do not. In some instances lightening is minimal or unapparent. In all instances, additional bleaching over time may be required to maintain the lightening originally obtained.

I have read and understand the above description of possible consequences of using home bleaching techniques. Being fully informed, I consent to and agree to use these techniques.

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Patient

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Doctor

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Print this page and fax it to our office at (949) 859-5042. Receipt of form is required prior to shipment.

Robert A. Milner, D.D.S.
27725 Santa Margarita Pkwy #120
Mission Viejo, CA 92691 (949) 859-8899