Ted Rothstein, DDS, PhD
Specialist in Orthodontics l Heights Center for Cosmetic Tooth Whitening
35 Remsen St., Brooklyn, NY 11201
l(718) 852-1551 lFax: (718) 852-1894  lE-mail: Drted35@aol.com
Internet Address: http://WWW.DRTED.COM

 INFORMED CONSENT

Cosmetic Tooth Whitening

Dr. Rothstein has provided me with list of thorough answers to important questions related to the teeth whitening procedure using the non-laser, "Plasma Arc"  blue-light emitting device known as the Apollo 95. In addition, he has answered to my satisfaction all other questions that I asked. He has made available to me any information I asked for related to this procedure. Finally, he has made me aware of his web site (www.drted.com) where further information can be obtained from many other informative sources including the American Dental Association.

In particular he has made me aware of the following:

1.      I should not do this procedure if I have a known sensitivity to peroxides or glycols.

2.   The possibility of sensitivity/discomfort/pain during or following the procedure.

3.      The possibility that treatment may not result in an appreciable/noticeable lightening of the color of my teeth and that some enamel stains may not respond al all.

4.      That my bridges, crowns, bonds, and white filling will not be bleached and in fact because the natural teeth may whiten this may cause me to have to redo some of my dental work to match the bleached teeth.

5.      That some teeth appear particularly grayish or dark-brown because of nerve death caused by previous trauma and/or root canal treatment and will not respond to power bleaching treatment.

6.      That if I have had any trauma to my front teeth in the last 12 months I should be aware the possibility of darkening of a tooth and the need for root canal treatment.

7.      That whatever the result, its maintenance and longevity will be related to: brushing 2-3 times each day, 2-3 minutes each time, using a whitening tooth paste (Rembrandt Dazzling White); having my teeth professionally cleaned every 6 months; the use of coffee, tea, cigarette smoking, tobacco products and other staining agents found in certain spices, i.e., (curry, saffron, paprika, tumeric), beverages i.e., (colas, ice tea) and condiments,  i.e,  (mustard, ketchup).

8.      That his staff is technically trained by him and is allowed by NY state to provide the power bleaching treatment.

9.      That the “Plasma Arc”  light procedure has been approved by the  FDA

10.  There is no guarantee as to the final result at the completion of treatment or in the months following.

11.  If you are displeased with the result within 60 days after the procedure we will refund one-third of the fee you paid, or charge you one–third of the fee you paid and redo the whitening.

12.  I have been advised that the best maintenance of the one hour whitening procedure is follow up use with custom fitted trays and the at-home whitening kit for which a surcharge is added.

 I have read the terms and conditions listed above and hereby give my permission for the power bleaching treatment to be given to myself/my child.

 Date:    /     /                            Signature: ______________________________________
                         

                                                Patient Name: _______________________________________