Teeth Whitening Consultation Form

Personal Details

Name

Date of birth *

Email Address

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal code

CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCaribbean NetherlandsCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SAR ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint HelenaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSouth KoreaSouth SudanSpainSri LankaSt. BarthélemySt. MartinSt. Pierre & MiquelonSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyriaSão Tomé & PríncipeTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTurks & Caicos IslandsTuvaluU.S. Virgin IslandsUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis And Futuna IslandsWestern SaharaYemenZambiaZimbabwe

Phone

Gender *MaleFemale

Medical & Dental History

Do you smoke or vape regularly? *YesNo

Do you drink tea/coffee/fizzy pop regularly? *YesNo

Are you currently pregnant/breastfeeding? *YesNo

When was your last dental check up? *

Have you had dental treatment within the last 6 weeks? *YesNo

Have you had your teeth whitened before? *YesNo

Have you ever had an allergic reaction to cosmetic or dental products? *YesNo

Are you currently experiencing tooth pain? *YesNo

Do you currently have sensitive teeth? *No sensitivityMild sensitivityModerate sensitivitySevere sensitivity

Do you have any of the following on your front teeth? (Tick all that apply) *CrownsVeneersComposite bondingBridgesDenturesBracesFillingsNone of the above

Do you suffer from gum disease, gingivitis, or bleeding gums? *YesNo

Do you have any oral infections, sores, ulcers, or open wounds? *YesNo

Are you currently under the care of a dentist for any ongoing issue? *YesNo

Do you have exposed roots or enamel erosion? *YesNo

Do you have any medical conditions we should be aware of? *

Are you currently taking any medication? *

Do you have any allergies? *

Please upload a clear photo of your smile. This helps to assess your teeth before your appointment and compare your results afterwards

Choose FileNo file chosenDelete uploaded file

Declaration & Consent

I can confirm the information I have provided is true and accurate *

I understand that teeth whitening is a cosmetic treatment, not a dental procedure *

I understand that results vary from person to person *

I understand that crowns, veneers, fillings and bonding will not whiten *

I understand that temporary sensitivity may occur *

I understand I may be refused treatment if deemed unsuitable  *

I understand I should avoid staining foods and drinks for at least 24-48 hours *

I understand smoking may affect results *

I understand I must follow the aftercare instructions provided *

I consent to Haus of Jay Beauty securely storing my images as part of my consultation record *

I give permission for my before and after images to be used for marketing purposes. I understand my identity will not be revealed without my permission *

Submit