"Free Lifetime Teeth Whitening Program”
Dental Associates of Houston
Jeremy W. Chance, D.D.S., P.A.

_____ Your journey to a more beautiful and brighter smile will begin with your participation in our NEW Free Lifetime Teeth Whitening Program.  In order to build a family of patients in our practice, we have created this program as a thank you to our patients for allowing us the honor of treating their friends and loved ones.  With two referrals to our office, you will receive a start-up bleaching kit free of charge, which includes three syringes of bleaching agent.  In addition, every 6 month recall exam, x-rays, and cleaning you will receive a free syringe of bleaching agent to maintain that beautiful smile. 

_____ Upon examination by the dentist, there may be circumstances which would not make a patient a candidate for the program.  You are not eligible to join this program if you currently have any of these dental conditions.  These exclusions are as follows:
          1.  6-month recall visit is missed
          2.  Gingival recession (teeth will become too sensitive for take-home bleaching)
          3.  Periodontitis (pocket depths of greater than 3mm) requiring deep cleaning
          4.  Active decay present
          5.  Tooth ache
          6.  History of sensitivity from past bleaching procedures
          7.  Permanent anterior restorations (do not respond to whitening)

_____ Teeth whitening is considered by the American Dental Association as a cosmetic procedure.  If you become sensitive through the use of these products, it is imperative that you disontinue the use of the product and inform us immediately.  Constant stimulation of soft tissues and teeth with bleaching agent may permanently damage the nervous tissue within the tooth or chemically burn the gingival tissues.  If the nerve within a tooth becomes overexcited (inflammation of the pulpal tissues inside the tooth), you may need root canal therapy followed by a build-up and crown to treat the symptoms and protect and seal the tooth.

_____ At your first visit to the office, an impression will be taken of your teeth.  This impression will be used to create a stone model, which will be used to make your bleaching trays.  A second visit is necessary to deliver the bleaching tray.  At this appointment, the dental assistant will review with you the proper way to bleach your teeth and answer any questions you may have about teeth whitening. 

_____ If sensitivity from bleaching agent occurs, discontinue and inform our office immediately.  Never use bleaching agent more than recommended by your dental professionals.  Be sure to follow the manufacturer’s recommended directions for use.

Congratulations!  Today you have taken the first step towards a lifetime of beautiful smiles!