Teeth Whitening
Consent Form

Queen, are you ready for your appointment? I know you are! In order to ensure you have the best service and consultation, please complete the waiver and questionnaire prior to your appointment. This will help the artist understand your lash history to suggest a gorgeous look!

Please complete the form to the right which includes both the Teeth Whitening Consent Form and COVID-19 Release.

Please review COVID-19 policy updates prior to signing consent forms. The COVID-19 Health Checklist must be signed prior to your visit.

Teeth Whitening & COVID - 19 Consent Forms

The Teeth Whitening Consent Form must be completed prior to your appointment. If you are a returning client and have not had lashes for a consecutive 60 days, you must complete the form again.

Liability Waiver

Client Treatment Consent/COVID-19 Release - UPDATED

Teeth Whitening/COVID-19

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General

I understand that I am participating in a professional teeth whitening procedure that is designed to lighten the color of my

teeth. I understand that I will be allowed to use a specially designed LED Lamp in order to accelerate the whitening

process.

Results Guarantee

Although most natural teeth can benefit from a teeth whitening treatment, I understand that everyone’s teeth are different

and that results will vary. I understand that people with yellowish teeth generally get the best results and that if my teeth

have spots due to tetracycline use (grayish tint) or fluorosis, these will be difficult to whiten. Also, if I have artificial teeth,

caps, crowns, veneers, porcelain, composite or other restorative materials, I shouldn’t expect dramatic results from this

treatment because the peroxide gel will not whiten (or damage) artificial dental work. Also, I am aware that my teeth

will never be whiter than the white color my genes naturally allow.

Potential Risks

Although whitening treatments are generally safe, I understand that some of the potential complications of this treatment

include, but are not limited to:

GUM/LIP IRRITATION: Whitening gel that comes in contact with gum tissue or the lips during the treatment may

cause inflammation or whitening of these areas. This is due to inadvertent exposure of small areas of those tissues to the

whitening gel. The inflammation and/or whitening of gums and lips is transient, and the color change of the gum tissue

will reverse within 30 minutes. I may feel a stinging and tingling sensation on these soft tissues during the treatment if the

gel comes in contact with them.

TOOTH SENSITIVITY: Although uncommon, some customers can experience some tooth sensitivity during the

first 24 hours after the whitening treatment. People with existing sensitivity, recently cracked teeth, micro-cracks, open

cavities, leaking fillings, exposed roots, or other dental conditions that cause sensitivity may find that those conditions

increase or prolong tooth sensitivity after the treatment.

SPOTS OR STREAKS: Some customers may develop white spots or streaks on their teeth due to CALCIUM

DEPOSITS that naturally occur in teeth. These spots are NOT caused by the peroxide gel. The gel just brings the already

existing calcium deposits out and makes them visible again. These usually diminish over time.

RELAPSE: After the treatment, it is natural for teeth color to regress somewhat over time. This is natural and should be

very gradual, but it can be accelerated by exposing the teeth to various staining agents, such as coffee, tea, tobacco, red

wine, colas, etc. I realize that I should not eat or drink anything except water during 60 minutes after the treatment because

the gel opens the pores of my enamel and makes my teeth very vulnerable to staining agents. If I purchase a touch-up pen,

I realize that my pores will remain open for as long as I use it so I should refrain from staining agents till I stop using the

pen. Only 24 hours after I conclude the touch-up pen treatment can I resume my normal habits. I understand that the results

of the treatment are not intended to be permanent and that secondary, repeat or touch-up treatments may be needed for me

to maintain the color I desire for my teeth.

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I understand if needed, I will seek medical care (at my own expense) and contact my technician immediately if any allergic or adverse reaction occurs. I acknowledge, that all of my questions were answered and I will ask any additional questions prior to my service. I understand the procedure and risks. I will seek medical care (at my own expense) and contact my technician immediately if needed. I grant permission to use my before and after photos and videos for marketing or examples of my technicians work to its' company and its' partner companies platforms, advertising methods, and advertising channels.

I understand that this treatment CANNOT be used by pregnant or lactating women, people under the age of 14, people with gum disease, open cavities, leaking fillings, or other dental conditions, or people with a known allergy to peroxide and/or to aloe vera. People that have had braces removed should wait 6 months for cement residue to wear off before getting a teeth whitening treatment and people with a piercing or other metal objects in the oral cavity should remove them before the treatment as they may turn black. If I feel a sharp pain on a particular tooth during the treatment I should stop the treatment and contact my dentist since this could be a sign of an open cavity. By signing this document, I indicate that I am not ineligible as per the criteria listed above, that I have read and fully understand this entire document including the possible risks, complications and benefits that can result from the treatment, and that

I acknowledged, I have read the COVID-19 policy update located at https://www.whippedstudios.com/covid-19 and agree to its terms. By signing the below and submitting you agree to comply with both written and verbal instructions. You also agree that you are entering the studio at your own risk, releasing Whipped Studios, LLC. and it's employees, members and contractors from liability relating to COVID-19. Failure to comply with studio policies may result in removal from the premises.

I understand that even though precautions are taken in my treatment, not all risks can be known in advance. I agree to unconditionally defend, hold harmless and release from any and all liability of Whipped Studios, LLC the lash technician, and all parties associated with my treatment. I release my certified lash technician and Whipped Studios , LLC from any and all liability associated with this procedure. I understand and agree that any legal action of any kind related to any treatment I receive will be limited to binding arbitration with a single arbitrator agreed to by both parties. This service will be performed with the utmost attention to safety, sanitation, and proper application using tools and products that the technician has been trained and certified as a "practicing/student" eyelash extension technician.

Whipped Studios does not employ some technicians located on this website ,LLC and are responsible for licensing certifications, and training in their states and cities. By signing below you understand that Whipped Studios does not supply licensing for any lash technician or independent contractors found within the site and you've verified that you've done your own research regarding technicians' work and background in addition to what Whipped Studios, LLC has done.

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COVID - 19 Release

Due to the recent outbreak of COVID-19, Whipped Studios is taking extra precautions with the care of every client to include health history and enhanced sanitation and disinfection procedures in accordance with the Australian Government Department of Health Regulations.

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Some of COVID - 19 Symptoms consist of but are not limited to:

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Fever, Fatigue, Dry Cough, Difficulty Breathing as well as our rigorous disinfection and sanitization procedures in the salon (view our COVID-19 WorkSafe plan here), we ask of you, our clients to please adhere to the following procedures to prevent the spread of COVID-19:

• No guests or children to accompany those scheduled for services

• Wash your hands upon entering the salon and before leaving

• Wear the mask provided by your technician during your appointment

• Avoid talking during an appointment where possible

• Keep your shoes on during the treatment

• Please be aware that we will not be able to provide blankets or soft furnishings for the time being, if you get cold easily, bring a jumper or your own blanket.

If you've checked any of the above, please understand we will not be able to proceed with treatment at this time. In order to proceed with an appointment, you must validate and be cleared by GP (Doctor) to show as COVID Negative.

If you have checked any of the above questions, we will be in touch with you to get more information.

BY COMPLETING THIS FORM AND SIGNING THIS ACCEPTANCE I AGREE THAT:

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The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, Whipped Studios has put in place many preventative measures to reduce the spread of COVID-19 (please see detailed preventative measures here); however, while we take all possible precautions, Whipped Studios cannot guarantee that you will not become infected with COVID-19. By signing this agreement, you acknowledge the contagious nature of COVID-19 and by attending an appointment at Whipped Studios you do at your own risk. You do certify that you do not currently have any symptoms of COVID-19. You also certify you have not knowingly been in contact with a confirmed case of COVID-19 in 14 days.

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I have read and answered the questions above truthfully. I have read, agree to the terms and conditions of this waiver.

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4672 W FLORIDA AVE, STE 103

HEMET, CA

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