Pre-selection questionnaire Safe teeth whiteningFind out if you’re eligible for teeth whitening? Pre-selection questionnaire Question 1 of 7 How old are you?* Under 1616–18 years oldAged 18 and overNot applicable You may continue with the questionnaire. Please note, however, that as you are aged between 16 and 18, you will need written consent from a parent or legal guardian to undergo in-clinic teeth whitening. Select one answer. Next Question 2 of 7 Are you?* A womanA manNot applicable Select one answer. Undo Next Question 3 of 7 Are you currently pregnant or breastfeeding?* YesNoNot applicable Select one answer. Undo Next Question 4 of 7 Are you currently undergoing treatment with fixed braces?* YesNoNot applicable Select one answer. Undo Next Question 5 of 7 Have you recently been found to have any untreated cavities in teeth 1 to 5?* YesNoNot applicable Select one answer. Undo Next Question 6 of 7 Have you been diagnosed with dental caries grades 1 to 5 in the last while?* YesNoNot applicable Select one answer. Undo Next Question 7 of 7 Have you been diagnosed with any of the following conditions: periodontitis, epilepsy, Parkinson’s disease or cancer?* YesNoNot applicable Select one answer. Undo Next ✓ The preliminary survey has been successfully completed Based on the responses provided, none of the contraindications listed in the questionnaire were identified. It is highly likely that you could benefit from a teeth-whitening treatment. Please note that if you are aged between 16 and 18, you will need written consent from a parent or legal guardian to undergo in-clinic teeth whitening treatment. The final assessment takes place in the surgery following an evaluation of the condition of the teeth and the ruling out of any contraindications. ! Unfortunately, you are not currently eligible for the procedure Your answer suggests that, at present, you are not eligible for teeth whitening treatment. If you’d like us to ring you, please leave your contact details. We’ll get back to you with a suggestion for resolving the issue or a proposed meeting time. You can also contact us. This questionnaire is preliminary and for information purposes only. If you have any questions or concerns, please contact the practice of your choice. Please provide your contact details Select a city*BialystokBielsko-BialaBydgoszczBytomCzęstochowaGdanskGorzów WielkopolskiKatowiceKielceKoninKoszalinKrakowLesznoLublinŁódźNowy SączOlsztynOstrów WielkopolskiSawPoznanRadomRzeszówSzczecinSzczecinekTarnówTorunWalczWarsawWloclawekWrocławZielona Góra If we are unable to reach you by phone, we will send you a text message, to which you can reply or call us back. I consent to the processing of my personal data for the purpose of handling this enquiry. I have read and understood privacy policy. Undo (+48) 887 167 548 kontakt@white-beauty.pl White & Beauty HeadquartersA. Mickiewicza St. 2860-836 Poznan Teeth whitening clinics
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