Dr Ted's new website is:
ojwforweightcontrol.com
As of January 1, 2017, Dr. Rothstein has limited his practice to providing Orthodontic Jaw Wiring for Weight-Control: OJW®: Weight-control. He provides this service in Brooklyn, NY and will soon announce a new office location in Portland,OR where the Oregon Board of Dentistry on June 23 created history by ruling that Dental Professionals are at liberty to Provide Weight-control services. See www.ojwforweightcontrol.com
Contact: 718 808 2656; drted35@gmail.com

The Informed Consent for Teeth Whitening

Ted Rothstein, DDS, PhD
Specialist in Orthodontics l Heights Center for Cosmetic Tooth Whitening
35 Remsen St., Brooklyn, NY 11201
(718) 852-1551 Fax: (718) 852-1894 E-mail: Drted35@aol.com

Internet Address: www.drted.com

INFORMED CONSENT

for the One-Hour 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, Rembrandt “ZOOM” blue-light whitening system 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:

Please note: The teeth that are whitened are the six upper and lower front teeth to allow safe control of the whitnening gel and because access

to the back teeth with the whitening light is not possible farther toward the back of the mouth

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

I have been advised to take an analgesic like Advil, Tylenol, aspirin, or Aleve 2 tablets three hours before the whitening procedure and then every six hours after the procedure for 24 hours in case of sensitivity.

2. And that such sensitivity can be further minimized by using a desensitizing toothpaste such as “Sensodyne” 3 times each day for 3 days before and 3 days after the day of the power whitening.

2.5 I realize that any time during the one-hour power whitening procedure if I am experiencing undue discomfort I can signal that I do not want to continue any longer.

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 at all.

4. That my bridges, crowns, bonds, and white fillings 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 6-18 months I should be aware of the possibility of darkening of a tooth and the need for root canal treatment as a result of that trauma. Whitening will never cause a tooth to darken.

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, turmeric), beverages i.e., (colas, ice tea) and condiments i.e., (mustard, ketchup).

8. Your gums will be protected/covered by a soft adherent material called a “dam” at the start of the whitening process. Nevertheless, the whitening agent may sometimes seep under it and touch the gums which can cause a temporary, harmless and painless white haze on them which will disappear over period of 1 -10 days. No treatment is necessary.

9. That the Rembrandt whitening system 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 14 days after the procedure we will refund one-third of the fee you paid.

12. For two days after the whitening I must avoid all dark-colored foods, beverages and tobacco as well as dark-black coffee in particular. Such foods may impart their coloration to the teeth. (See 7 above.)

13. I have been advised that the best maintenance of the one hour whitening result is achieved by use of custom-fitted “trays” made for me by Dr. Ted. These trays are used at home once a week in conjunction with the take-home teeth whitening kit the office provides. I have been advised that use of excessive/incorrect use of whitening liquid may make my teeth sensitive and even irritate my gums . The trays and kit are provided at an additional cost.

14. Regarding the take-home whitening kit when used as maintenance to the in-office whitening procedure or when use as the whitening treatment itself:

-The bleaching agent is similar to that used in the in-office whitening procedure, but not as concentrated.

-The bleaching gel must be sparingly painted as thin film on the front (inside surface) of the custom-fitted tray that was fitted for you.

-If the gel is improperly used and flows over the gums it may cause damage to the gums.

-Incorrect use of the gel may cause the gums and teeth to become sensitive,

-For active whitening apply the gel two times each day: after a meal, and/or before going to bed. Results are apparent in 10-14 days. You may not be aware of the change since you have no way of knowing/ remembering how the teeth looked at the starting point.

-The effects of the gel are largely dissipated in 30-45 minutes by your own saliva.

-When no appreciable whitening is observed after 2-3 weeks apply the gel once each week as a maintenance treatment until you run out of whitening gel.

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: _______________________________________

"Experience and reputation really count when it comes to providing quality patient care."