Fill and Sign the Waiver Release Liability Form

Consent, Waiver and Release from Liability, and Assumption of Risk for Teeth Whitening Treatment Whereas, _____________ Teeth Whitening (_________) provides the service of whitening teeth in a mobile unit owned and operated by ____________; and Whereas, the undersigned _________________ (name of customer), hereafter called Customer , desires to use the said services of ____________; Now, therefore, for and in consideration of using the teeth whitening services offered by _____________ (said services being hereafter referred to as service or services ), and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the undersigned Customer does hereby waive and release _____________ , its agents, employees, officers, directors, affiliates, successors and assigns (hereinafter jointly and severally called Releasees ), of and from any and all claims, demands, debts, contracts, expenses, causes of action, lawsuits, damages and liabilities, of every kind and nature, whether known or unknown, in law or equity, that I ever had or may have, arising from or in any way related to the services being provided to me by Releasees , provided, however, that this waiver of liability does not apply to any acts of gross negligence, or intentional, willful or wanton misconduct. The undersigned Customer understands that tooth sensitivity and gum irritation may result from this service and that teeth whitening will not work on crowns, veneers or composite fillings and may result in different colored teeth unless the crown or veneer is replaced. Customer understands further: A. If Customer has gum disease, cavities, or worn tooth enamel, the service may not be effective. B. If Customer’s teeth are severely stained by tetracycline then Customer might not experience a dramatic improvement from the service without prolonged treatment. C . Tooth whitening is not recommended for children under the age of 16. At this age the teeth are still developing and the nerves are enlarged. Teeth whitening could cause sensitivity and possible damage to the teeth. D. Dentists do not recommend teeth whitening for women who are pregnant or lactating. Swallowing even the smallest amount of whitening bleach can be harmful to a fetus. E. Anyone allergic to peroxide should not use a teeth whitening product. F. Results depend upon the individual’s genetics, the condition of the teeth, and the whitening method used and whitening is not permanent. By this Waiver, the undersigned Customer assumes any risk, and takes full responsibility and waives any claims of personal injury associated with such services. This Waiver and Release contains the entire agreement between __________ and myself, and supersedes any prior written or oral agreements concerning the subject matter of this Waiver and Release. The provisions of this Waiver and Release may not be waived, altered, amended or repealed, in whole or in part, without the prior written consent of ____________ and myself. The provision of this Waiver and Release will continue in full force and effect even after the termination of the services being provided to me, whether by agreement, by operation of law, or otherwise. I have read, understand and fully agree to the terms of this Waiver and Release. I understand and confirm that by signing this Waiver and Release I have given up considerable future legal rights. I have signed this Agreement freely, voluntarily, under no duress or threat of duress, without inducement, promise or guarantee being communicated to me. My signature is proof of my intention to execute a complete and unconditional Waiver and Release of all liability to the full extent of the law. I am 18 year of age or older and mentally competent to enter into this Waiver and Release. WITNESS my signature this the day of , 20 . ___________________________ CUSTOMER