Effective Date: June 23rd, 2026

1. Cosmetic Service Acknowledgment

I understand that Orisha Teeth Whitening is a non-medical cosmetic teeth whitening business and not a dental or medical practice.

I understand the services provided are cosmetic in nature only.

2. Voluntary Participation

I understand that I voluntarily self-administer cosmetic whitening products while receiving general guidance and cosmetic application support from staff members.

I understand I may discontinue cosmetic whitening services at any time.

3. Health & Dental Responsibility

I confirm that:

• I do not have untreated dental conditions that would make whitening inappropriate;

• I have disclosed relevant concerns to the staff member;

• I understand whitening is not recommended for certain dental conditions.

• I understand I should consult a licensed dentist regarding dental concerns.

4. Eligibility Acknowledgments

I confirm that:

• I am over the age of 18;

• I am not pregnant, suspected to be pregnant, or breastfeeding;

• I do not have known allergies or adverse reactions to peroxide, carbamide peroxide, or glycerin;

• I am not photosensitive and am not currently using photosensitive medications;

• I do not have untreated tooth decay, periodontal disease, or gingivitis;

• I do not have open wounds, bleeding, or irritation within my oral cavity;

• I have not undergone dental surgery or extractions within the last 30 days;

• I am not wearing oral jewelry or metal objects that may interfere with cosmetic whitening services.

5. Minor Consent (If Applicable)

If the client is under 18 years of age:

• A parent or legal guardian must be present or provide verified written authorization;

• The parent or legal guardian must sign this waiver on behalf of the minor;

• The parent or legal guardian assumes full responsibility for consent, participation, and outcome acknowledgment;

• The parent or legal guardian confirms understanding of all risks, aftercare requirements, and cosmetic nature of the service.

The signing parent or guardian agrees that they are fully responsible for the minor’s participation and waive liability on behalf of both themselves and the minor to the fullest extent permitted by law.

6. Understanding of Risks

I understand possible side effects may include:

• Temporary tooth sensitivity;

• Gum irritation;

• Uneven whitening;

• Temporary discomfort;

• Limited or inconsistent results.

• I understand results vary between individuals.

7. No Guaranteed Results

I understand no guarantees have been made regarding:

• Shade improvement;

• Length of results;

• Uniform whitening;

• Whitening of crowns, veneers, fillings, or restorations.

8. Release of Liability

To the fullest extent permitted by law, I release and hold harmless Orisha Teeth Whitening, its owners, employees, contractors, representatives, affiliates, successors, and assigns from claims, liabilities, damages, expenses, losses, costs, or causes of action arising from or related to cosmetic whitening services, products, participation in services, or reliance upon information provided in connection with such services, except where prohibited by applicable law.

9. Aftercare Responsibility

I understand that following aftercare instructions is my responsibility and may affect results.

10. Media Consent Reference

I understand that media usage permissions are governed separately through the Media Release & Content Consent Agreement.

My media authorization preferences, if provided, shall be governed by that agreement.

11. Contact Information

If you have questions regarding this document or our policies, please contact:

Orisha Teeth Whitening

1521 Locust St.

Philadelphia, PA 19102

445.202.9737

support@orishateethwhitening.com

orishateethwhitening.com

Version Note: This document may be updated periodically. Continued use of services constitutes agreement to the most current version