777 WELCH ROAD • PALO ALTO, CA 94304-1691
STATEMENT OF INSTRUCTIONS AND CONSENT FOR ZOOM BLEACHING:
Zoom2 Chair-side Whitening involves a series of steps: Isolation of you gums and
lips, three 15-minute Gel and Light Applications and a Post Treatment Satin Finisher.
Depending upon your teeth’s sensitivity level, you may or may not have some
sensitivity during and/or after the treatment. There may only be a slight warming
sensation or there could be a greater degree of sensitivity which could include a
“zinger”, “zapping” or aching sensation in your gums and/or teeth. This sensitivity
may start during the Gel and Light Application and may continue and dissipate over
12 or more hours after completion of the treatment.
Prior to your treatment we recommend you eat and then take two 200mg of Advil,
Ibuprofen or Motrin to help minimize this sensitivity. You may want to take
additional doses throughout the day or night, depending on you needs. If you have
had previous tooth sensitivity, we recommend that you do not return to work the
We also recommend you apply a SPF 15 or greater lotion to your face prior to the
treatment. If this is not possible, then we recommend you allow us to apply one. If
you choose for us to apply it, we request that you remove your makeup prior to
For the greatest results, it is recommended that you receive your oral cleaning prior
The first 48 hours after your treatment are important in enhancing and maximizing
your whitening results for a long lasting, bright and healthy smile. For 48 hours
after treatment, dark staining substances should be avoided; such as our suggested,
but not all inclusive list of items to avoid.
2. I have had an opportunity to ask sufficient questions.
3. I had my last cleaning on ______________ and have chosen to
proceed/not proceed to the Zoom2 Bleaching Treatment.
4. I have taken/not taken a suggested dose of Advil, Ibuprofen or Motrin
5. I have chosen to apply a facial cream of SPF 15 or above prior to my
6. I have removed my makeup and request the office to apply SPF 15
7. I do realize the first 48 hours after treatment are important in
enhancing and maximizing my whitening results and will not eat
or drink anything that may darken or stain my teeth.
8. I understand I may have sensitivity, which may last 12 or more hours during
and after treatment, such as but is not all inclusive of:
A. Warm sensation to my gums and/or lips which may last
B. Zingers, zapping or aching to individual teeth which may last
C. Prolonged soreness or tenderness to the teeth.
9. I will notify the doctor immediately if I should have any other
10. I will/will not be returning to work today.
11. I have read and initialed the attached Proactive Drug Information
that is attached and acknowledge that I do not currently take any of these
12. I authorize the office of Cox & Miranda, DDS to apply the Zoom2
13. I certify that I read write English and have read and fully understand
that consent for the bleaching treatment.
PLEASE ASK THE DOCTOR IF YOU HAVE ANY OTHER QUESTIONS REGARDING THIS
Patient’s signature (or legal guardian if under 18) Date
The following medications are commonly considered to be photo-reactive and may cause an
adverse condition if used in conjunction with the Zoom System. If you are currently taking
any of these medications, please consult your physician before going through the Zoom2
System. To check photo-reactive properties of any medications not listed below, please
consult the most recent edition of the Physician’s Drug Reference (PDR).
Aldacteride, Aldoril, Capozide, Dyazide,
I have read the list above and understand that the medications listed, if taken, can have an
adverse reaction when used with the Zoom System. I also acknowledge that I do not
currently take any of these prescribed medications.
WHAT IS CYCLOPHOSPHAMIDE? Cyclophosphamide is a drug in a class of chemotherapymedications called alkylating agents which are used to treat varioustypes of cancer. It may also be referred to as Cytoxan®. HOW DOES CYCLOPHOSPHAMIDE WORK? Cyclophosphamide prevents the growth and multiplication ofcancer cells, ultimately leading to cell death. HOW IS CYCLOPHOSPHAMIDE ADMINISTERED? Cyclo