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Client Intake & Waiver

Text us to agree your service, location and appointment time. Complete intake when requested. Your appointment is confirmed by text; submitting intake alone does not reserve a time.

Complete intake and waiver

Birthday
Month
Day
Year
Why are you looking to whiten your teeth?
Which habits affect you most?
Which service interests you the most?
60 min — $200
90 min — $300
First-Time Duo — two 60-minute sessions, $350 total
First-Time Duo — two 90-minute sessions, $550 total
Are you currently pregnant or breastfeeding?
Yes
No

We do not provide whitening services during pregnancy or breastfeeding. If you answered Yes, please do not proceed with this form. Contact us if you have questions or would like to schedule for a future date.

Age confirmation
I am 18 or older
I am 16 or 17

You must be at least 16 for whitening — we check this against the birthday you entered above. If you're 16 or 17, your parent or legal guardian must be present at the appointment and complete the guardian section on the next step.


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