INFORMED CONSENT FOR INTERNAL BLEACHING (SINGLE

Dr. Alan Wonhee Lee, DDS, MS

Dr. Steven Kim, DMD

11800 Sunrise Valley Drive, Suite

#250 Reston, Virginia 20191

703-429-9926

www.endoreston.com

INFORMED CONSENT FOR INTERNAL BLEACHING (SINGLE TOOTH WHITENING)

TOOTH #___________

The purpose of this informed consent form is to provide written information regarding the risks, benefits and alternatives

of the procedure named above. This material serves as a supplement to the discussion you have with your

doctor/healthcare provider. It is important that you fully understand this information, so please read this document

thoroughly. If you have any questions regarding the procedure, ask your doctor/healthcare professional prior to signing

the consent form.

THE TREATMENT

The purpose of internal bleaching is to lighten or whiten the cosmetic appearance of a single discolored tooth. Internal

bleaching is a biological procedure and therefore there is no guarantee or warranty relating to the cosmetic outcome.

Internal bleaching may require multiple office visits. Therefore, the patient must return for all additional appointments at

the time specified by the doctor. The patient’s failure to return for appointments or complete treatment within the

specified period may result in an undesirable cosmetic outcome, loss of the tooth or other problems or complications that

may require additional treatment with additional fees at the patient’s sole expense.

RISKS AND COMPLICATIONS

I understand that the most common risks and complications related to internal bleaching include, but are not limited to:

External resorption

• Internal resorption

• Reaction to bleaching agent

• Over whitening or under whitening

• Recurring discoloration

• Pain or tenderness of the tooth following treatment due to possible complications or normal post operative

response.

These complications may require additional endodontic intervention or extraction of the tooth.

ALTERNATIVE PROCEDURES

Alternative treatment choices include no treatment or other dental procedures such as crowns or veneers to achieve

cosmetic outcomes.

I understand this is an elective procedure and I hereby voluntarily consent to treatment with internal bleaching. The

procedure has been fully explained to me. I also understand that any treatment performed is between me and the

doctor/healthcare provider who is treating me and I will direct all post-operative questions or concerns to the treating

clinician. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and

complications of the procedure and I understand that no guarantees are implied as to the outcome of the procedure. I