Teeth whitening intake form Name * First Name Last Name Email * Date of birth * Phone * Expecations You may feel a slight tingling or minor blanching of the gums, this is normal and will usually disappear in less than 4 hours. Your teeth will never be whiter that your genetic traits. White spots may appear if you had braces, or have porous enamel, this will disappear in 8 hours. The whitening gel is PH balance neutral and will not damage your enamel, caps, crowns, or veneers. Please be advised, your teeth can only be whitened to a certain shade and cannot go whiter than your genetic traits will allow. Release (Fill in name below) * I ,_______________________, in consideration of the services provided, hereby release GLO XO, its distributors and or dealers from all manner of actions, cause of action, which may arise from the use of any products, services or services provided. Thank you!
