This Disclaimer Form is reviewed and signed by all of our customers. Please right click on the icon below to download and save this form. Thank you!

DISCLAIMER FORM:

Agree to the following: (by initialing each of the following)

· To take impressions of my own teeth myself, personally (_______)

· Do not have loose or decaying teeth/crowns or periodontal/gum disease (_______)

· To consult my physician if I experience any problems while using this product (_______)

· Acknowledge that the staffs of Your Dentist’s Lab Direct are not dentists, but Certified Dental Lab Technicians (_______)

· Acknowledge that this dental appliance is customized to my teeth, therefore not exchangeable (_______)

· Will not have allergic reactions to Vinyl Polysiloxane, Sodium Fluoride, 22% Carbamide Peroxide, Glycerin,Carbome, Sodium Hydroxide, Hydrogen Peroxide, Ammonium, Hydroxide, or Silicone (_______)

· To understand that the actual effects of bleaching one’s teeth and its duration may vary (_______)

· Won’t use Carbamide Peroxide (22% CP) if pregnant or nursing, unless consulted by a dentist (_______)

· Acknowledge 22% Carbamide Peroxide  will not whiten any present restorations (crowns/veneers/fillings/bridges,etc.) (_______)

· Acknowledge the Your Dentist’s Lab Direct guarantee is that which is expressly written with none implied (_______)

· Acknowledge that Your Dentist’s Lab Direct is not responsible for any tooth and/or gum sensitivity (_______)

· Acknowledge that total liability is limited to the price of product (_______)

  Please right click on the icon below to download and save this form.