GTW Generic Consent for Japan by sofiaie

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									GTW Generic Consent Form    6/13/07   8:12 PM    Page 1




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            Gentle TouchTM Whitening
                        TM


           Guest Consultation and
                     CONSENT
                      FORM
          Guest Name:____________________________________Location:____________________________________
          Address:_______________________________________Room # ___________________Date:______________

          Welcome to GentleTouch™ Whitening! Your GTW™ technician will explain the entire process in
          detail as well as answer any questions you may have regarding the whitening procedure.

          While GentleTouch™ Whitening is a safe procedure that is suitable for most though not all people, all teeth
          are different and; certain tooth conditions whiten better than others. Uniformly yellow teeth tend to produce
          the best whitening results. Blue-Gray/damaged teeth will not whiten as much. Please review the following con-
          ditions and indicate whether you now experience or are being treated for the following conditions:

          Are you allergic to nuts?**                                       ___________________
          Do you have unfilled or broken cavities that are sensitive?       ___________________
          Do you wear braces in the front of your teeth?                    ___________________
          Are you pregnant?                                                 ___________________
          Do you suffer from severe asthma attacks?                         ___________________

          If you have answered yes to any of the above questions, consult your dentist/doctor before undergoing this treat-
          ment.
          ** If you are allergic to nuts you should NOT use the swabs.The Revitalizing Swabs used to soothe the gums and lips
          during and after the treatment are filled with Aloe Vera, vitamin E and sunflower and almond oils.

          While GentleTouch™ has taken steps to minimize any potential risks associated with this procedure there is a
          slight chance that you may experience the following effects during and/or following your procedure:

          I Soreness and peeling in gums and around the teeth, which can last up to a few days.
          I Uneven whitening due to existing dental conditions, genetics or damaged teeth.
          I Coughing during procedure.

          You should avoid the use of tobacco and tooth-staining foods and/or beverages immediately following the initial
          treatment. Foods and drinks such as tea, coffee and red wine can prevent you from achieving the best possible
          whitening results.

          In order to obtain the maximum whitening results, it is recommended that you use the GTWTM Brush-On
          Enhancer for fourteen, (14) days following your treatment.




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GTW Generic Consent Form        6/13/07     8:12 PM     Page 2




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              Gentle TouchTM Whitening
                          TM


           Guest Consultation and
                       CONSENT
                        FORM
          CONSENT

          I    The risks and responsibilities have been explained to me.
          I    I will have the opportunity to ask questions and they have been answered.
          I    I have read this entire agreement and believe I am a suitable candidate for the procedure.
          I    I understand that GTW and or the Spa make no guarantees as to the level of
               whitening achieved. Whitening will vary from guest to guest and it can not be accurately predicted.
               I further understand that maximum results will be reached by utilizing the enhancer at home.
          I    Bonding, porcelain, acrylic caps or crowns will only whiten to original color.
          I    I understand that yellow or brownish teeth are easiest to whiten; blue, grey or opaque are more
               difficult to whiten; damaged or tetracycline stained teeth are difficult to whiten.
          I    I have provided true and accurate information regarding my dental and health history on this
               form and to the attendant providing the treatment.
          I    I understand that the technician providing my treatment is not a dentist and makes no claims as
               to the suitability of my dental or health condition.

          LIABILITY RELEASE, ACKNOWLEDGEMENT AND WAIVER

          The undersigned, understands, acknowledges and agrees that: (i) I am aware that the facilities and services offered by the Spa involve risks:
          (ii) I have provided above all the relevant information regarding my dental and medical history and current health status: (iii) I am seeking
          the whitening procedure at my own free will; and (iv) I assume all risks associated therewith. On behalf of myself and my heirs I hereby
          release and dischargethe entity that operates the Spa (the “Owner”) and all of the affiliates, subsidiaries, employees, directors, officers,
          agents, landlords, representatives, successors and assigns of the Owner from any and all claims or causes of actions arising out of or relating
          to my receiving teeth whitening services and services of that entity, including but not limited to, those resulting from bodily injury, theft,
          loss of, or damage to, property of mine unless due to the gross negligence or willful misconduct of the Owner or its employees.

          Guest Signature______________________________________________________________

          Technician__________________________                         Technician Signature__________________

          GUEST INFORMATION

          Top Shade :                          Start Shade _______                End Shade ____________

          Bottom Shade :                       Start Shade _______                End Shade ____________

          Shade Change                         T__________________                B ____________________

          Location                             ____________________________________________

          Technician Name                      ____________________________________________

          Additional Comments     ___________________________________________________________________
          ___________________________________________________________________________________________




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