Smiles by Natasha

Complimentary Online Consultation

Please answer all questions denotated with a *
This complimentary online consultation is required for all teeth whitening products which exceed 6% hydrogen peroxide and 18% carbamide peroxide

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MEDICAL HISTORY

It is important to know details about your medical history as these could affect your suitability for teeth whitening treatment and how we can provide this treatment safely for you. The information you provide is confidential and will be handled in accordance with our privacy policy.

Name
Date of Birth
Please note products are not to be used by persons under 18 years of age
Unfortunately this product is not available for you
Are you taking any medication or supplements?
Have you been hospitalised in the last 12 months?
Allergies
Are you receiving any medical treatment at present?
Women, are you currently pregnant?
Breastfeeding?