Laser Teeth Whitening - The Body Studio Treatment Form

The Body Studio, LLC Laser Teeth Whitening Treatment Form
The patient receiving services from a laser technician at The Body Studio, LLC (or the Guardian of the patient) must complete the following information before the first treatment session.
Patient Name *

First Name Last Name
Date of Birth *
For Patient
Date of Birth

Month Day Year
For Patient
Mobile Number *

Area Code Phone Number
Other Number (optional)

Area Code Phone Number
Physical Address *

Street Address

City State / Province

Postal / Zip Code
Email *
We may send you special deals from time to time by e-mail which you will be able to opt-out of at anytime.
How did you hear about us? *
Who referred you? *
If other, please specify: *
Do you have a coupon? If so, please enter the coupon code or description:
Text Body2019 to 555-888 for Exclusive Coupons
Have you ever whitened your teeth before? *

YES NO
If yes, please specify (at home treatments or in-office laser etc.)
Leave blank if you answered NO to the last question.
Do you regularly take medications such as tetracycline, antacids, doxycycline, etc.? *

YES NO
If YES, please list all:
Leave blank if you answered NO to the last question.

Check YES or NO on the following questions: *

YES

Do you smoke?

Do you drink dark soda, tea or red wine?

Do you have any artificial teeth (crown, bridges, implants etc.)?

Do you have any allergies? Latex, nickel, etc. *

YES NO
Do you use whitening tooth paste or mouth wash?

YES NO
If YES, what brand(s):
Leave blank if you answered NO to the last question.
Are your teeth normally sensitive when you brush or whiten?

YES NO
CONSIDERING OTHER SERVICES?
What areas have you considered treatment for today or in the future?

Body Fat Reduction Hair Removal Skin Rejuvenation Pigmentation Veins/Rosacea Tattoo/Scar Removal Acne/Acne Scar Anti Aging (Facial) Anti Aging (Body) Acne Treatment (Facial) Acne Treatment (Body) Skin Resurfacing/brightening Relaxation/unwind (massage) Reflexology/Zone Therapy
The Body Studio, LLC Laser Teeth Whitening Treatment
Cancellation Policy:

If you're unable to make your next appointment, The Body Studio requires that you inform them a minimum of 24 hours before the appointment by either text message or phone call to the office number (417) 771-8585. After two no shows, prepayment for your next appointment will be required.
I authorize the staff and members of The Body Studio, LLC to perform the following laser treatment procedures: Hair removal, skin rejuvenation, fat reduction, pigmentation reduction, veins/rosacea treatments, tattoo/scar removal treatments, acne/acne scar treatments and/or red blood vessel reduction, Spa Facials, Massage Therapy and Laser Teeth Whitening.

I understand that multiple treatment sessions may be necessary to achieve my desired results.
I agree to allow The Body Studio, LLC to use photographs of the treated areas for documenting and monitoring of the treatment progress only.

By signing this form (The Body Studio, LLC Laser Teeth Whitening Treatment) you and anyone claiming on your behalf can not hold The Body Studio, LLC, its affiliates, successors and assigns, officers, employees, representatives, partners and agents liable for past injuries, future injuries or damages of any kind.
Patient Name: *

First Name Last Name
Guardian Name (if applicable):

First Name Last Name
Date you completed this form: *
Date
Date you completed this form:

Month Day Year
Date
Patient or Guardian Signature (use your finger or iPen) *

If you’re the legal guardian of the patient receiving services from The Body Studio, LLC, you’re agreeing in its entirety to The Body Studio, LLC Consent for Treatment form on the patients behalf. Clear
Should be Empty:

The Body Studio, LLC Laser Teeth Whitening Treatment Form

The Body Studio, LLC Laser Teeth Whitening Treatment