Naturally White Consent Form

Naturally White's Aligner Program offers an easy path to a stunning smile without the need for surgery or traditional braces. By connecting you with a dentist, Naturally White provides a set of clear, 4D Smart Print aligners that gently move your teeth into a better alignment. These aligners are customized for each phase of the treatment, which generally takes between 4 to 12 months. The following details will help you determine if Naturally White’s Aligners and whitening products are suitable for you, including their long-term benefits, possible challenges, and associated risks. For any questions or concerns, Naturally White’s customer care team is ready to help you achieve your goals.

Benefits

Naturally White provides clear aligners crafted from BPA-free plastic. Unlike conventional braces, these aligner trays are subtle because of their clear, slim, and lightweight construction. The aligners are removable, so you can eat, brush, and floss as usual, sidestepping the common issues associated with braces. Plus, the whitening system included helps brighten your teeth throughout the treatment, enhancing overall oral hygiene.

Risks

Naturally White clear aligners are not suitable for everyone and may pose certain risks, including:

Allergic Reactions – Some individuals may experience allergic reactions to the materials used in the aligners. If you notice any adverse effects, stop using the aligners immediately and notify both us and your primary care provider.

Discomfort – You might experience some discomfort as your mouth adapts to the aligners, including irritation of the gums, cheeks, or lips. Changes in your bite during treatment can cause temporary discomfort and may necessitate adjustments after using the aligners.

Black Triangles – When teeth that have been overlapping for extended periods are aligned, gaps known as "black triangles" can appear below the contact points between them, due to a lack of gum tissue.

Damage to Nerves in Teeth – The movement of teeth can potentially cause nerve damage or death, possibly resulting in the need for a root canal or other dental treatments, and even tooth loss. While predicting nerve damage is difficult, those with previous dental injuries or restorations are at greater risk. If nerve damage is detected by your dentist before or during treatment, you may need to stop using the aligners to avoid tooth loss.

Cavities, Gum, or Periodontal Disease – Using aligners may lead to or worsen cavities, tooth decay, gum inflammation, periodontal disease, or permanent markings like decalcification. These issues are more likely if you frequently consume sugary foods or drinks, fail to brush and floss before wearing aligners, or do not attend dental check-ups every six months. You might also experience discoloration, white spots, increased sensitivity, tooth breakage, gingival inflammation, or soreness. Unchecked periodontal conditions could eventually cause tooth loss and require additional dental treatment.

General Health Issues – Medical conditions such as bone, blood, or hormonal disorders, as well as certain medications (including bisphosphonates), can impact tooth movement and affect treatment results.

Oral Piercings – It is advisable to remove any oral piercings during aligner therapy. Keeping them in place can lead to damage to the aligners or teeth, potentially disrupting your treatment.

Impacted and Supernumerary Teeth – Teeth that are impacted or trapped beneath the bone or gums, as well as extra teeth (supernumerary teeth), may not be suitable for alignment with the aligners. You may need to use the Impression Kit to determine if Naturally White aligners are appropriate for you.

Previous Dental Treatment – Aligners cannot adjust implants and may not be effective with certain dental restorations, such as bridges. Additionally, you might need to replace dental restorations like crowns or veneers due to the movement of your teeth.

Safety – Aligners can break, be swallowed, or be inhaled. There is also a risk of allergic reactions to the materials used in the aligners.

Temporomandibular Joint Dysfunction (TMJ) – Aligner therapy may lead to issues with the jaw joints, potentially causing pain, headaches, or ear discomfort. Factors such as past trauma, arthritis, hereditary conditions, tooth grinding or clenching, and certain medical conditions can contribute to these problems.

Supraeruption – If an aligner does not adequately cover a tooth, it may migrate outward, a condition known as supraeruption. This can lead to difficulties with cleaning, gum disease, tooth decay, and ultimately tooth loss.

Root Shortening/Resorption – Some customers may experience root shortening, or resorption, during aligner use. While this is not predictable, individuals with a history of braces are at higher risk. This condition can impact the long-term health of your teeth, and if identified by your dentist, you may need to stop treatment to avoid potential tooth loss. Additionally, resorption can accelerate in primary (baby) teeth, leading to their premature loss.

Molars – Naturally White aligners generally do not move molars and might not always cover them adequately.

Wisdom Teeth – Most people can use Naturally White aligners even if they have wisdom teeth. Nonetheless, it's advisable to consult with a family dentist or oral surgeon to evaluate if and when wisdom tooth removal might be necessary.

Temporary Side Effects – You may notice temporary changes in your speech or salivary flow due to the aligner tray.

Conditions for Which Naturally White Aligners Are Not Recommended:

• Severe open bites
• Severe overjet
• Severe overbite
• Tooth malocclusion requiring surgical correction
• Mixed dentition (both infant and adult teeth)
• Dental prosthetics or dental implants
• Active periodontal disease
• Active tooth decay or dental caries
• Permanent retainers
• Mental illness
• PETG material allergy

Warning: In rare instances, some people may be allergic to the plastic aligner material or other included materials. If you experience an allergic reaction, stop using the aligners immediately and contact a healthcare professional. Orthodontic appliances can be accidentally swallowed or aspirated and may be harmful.

Naturally White is suitable for non-bone malocclusion deformity correction. When in doubt, play it safe. Contact a healthcare professional if you experience any adverse effects and reach out to us anytime.

The information below will help you decide whether Naturally White’s straightening and optional whitening products are right for you, including their lasting benefits, potential challenges, and associated risks.

Nighttime Aligners Risks: All the risks identified here also apply to Naturally White’s Nighttime Aligner Program. Nighttime Aligners offer the advantage of not having to wear aligners all day and removing them in front of friends and family, as well as the benefit of removing and replacing aligners less frequently. Nighttime Aligners should be placed on after dinner and removed before breakfast, unlike standard aligners that must be removed and replaced at each meal. However, Nighttime Aligners require longer correction time, typically averaging five to six months, but your correction time will vary. Nighttime Aligners may cause more discomfort than standard treatment due to additional strain on your teeth after having the aligners off for long periods each day. Nighttime Aligners may increase the risk of root damage described above and could cause daytime wiggling of teeth and slower whitening effects. After treatment, Nighttime Users may also experience a higher likelihood of shifting post-treatment, requiring vigilant retainer use to maintain alignment. Nighttime Aligners are best suited for mild crowding and spacing issues and may provide better results with standard alignment treatment.

Other Risks and Warnings:

Naturally White’s Aligner Program is not intended as a replacement for regular dental examinations and care. Orthodontic treatment and tooth movement come with inherent risks and side effects, including discomfort, swelling, sensitivity, numbness, sore jaw muscles, allergic reactions to dental materials, and unforeseen conditions that may require extending the original procedures or recommending other specific treatments. Additionally, the tissue attachment between the front teeth may become inflamed, a common result of aligner therapy. The procedure to treat this, known as a frenectomy, is not part of the Naturally White treatment but is recommended for the best outcome and long-term stability of your smile.

Duration and Results

The length of time you wear the aligners and the results depend on many factors, including the severity of your case, the shape of your teeth, and the amount of time you wear the aligners each day. The average person generally wears the aligners for 4 to 8 months, but your specific rate of tooth movement is unpredictable and could take longer. If the duration extends beyond the original estimate, additional fees may be assessed. Difficult cases may require interproximal reduction (IPR) and/or extractions with traditional braces for optimal results.

Do not discard your aligners at any point until your treatment is 100% complete and you have retainers. If you are asked to revert to a previous aligner, for example, if you lose an aligner, it is essential to have all your previous aligners available.

Future Retainers

Teeth may shift after you stop wearing the aligners. Retainers are required to keep your teeth in their new positions for a lifetime. You should wear your retainer full-time for the first 2 weeks, and then nightly thereafter. A retainer typically lasts no more than one year, but this can vary. Due to wear and tear, we recommend purchasing new retainers at least once every six months. To qualify for the Naturally White for Life Guarantee™, you must: 1) purchase retainers from Naturally White or another source (with valid proof of purchase shown annually after your last retainer purchase from Naturally White) and 2) confirm at least once per year that you are actively using your retainers as directed.

Impression Kit

In rare cases, people may have an allergic reaction to the materials used in the Impression Kit. If you have concerns, please contact Naturally White for a complete list of ingredients. As with any dental impression, damage or loss of tooth structure, crowns, bridges, implants, bonded retainers, or other dental work is possible. Do not use the Impression Kit with partials.

Do not ingest the Impression Kit material. If ingested and you experience any health problems, seek medical attention. There is also a choking hazard, so please exercise appropriate caution.

Naturally White and clear aligner therapy should not be used by people with active periodontal disease.

Whitening Risks

Type of Discoloration – The whitening system will not lighten all teeth or restorations. Blue, gray, multi-colored, or striped discoloration may not respond to whitening. Areas of the tooth near the gum line affected by gum recession or periodontal disease may not respond to whitening. Similarly, fillings, cavities, or other damage will not lighten. Use of cigarettes, wine, coffee, tea, and similar stain-producing agents will also slow the whitening process.

White/Tooth-Colored Fillings – White or tooth-colored fillings will not lighten and may become softer after using the whitening system. These fillings may need to be replaced after whitening to match lighter teeth or if they become soft.

Pregnancy – For women who are or may become pregnant: While you may start or continue treatment during pregnancy, you must receive authorization from your treating physician before starting or continuing aligner treatment. Although you do not need to provide this authorization to Naturally White, it is your obligation to communicate with your doctor before starting or continuing the aligner process during pregnancy.

Sensitivity and Irritation – Gum irritation may arise from excessive use of the whitening system, as may throat irritation if the whitening agent is swallowed. Tooth sensitivity may occur during initial use. Additionally, discomfort and possible permanent nerve damage can occur if the whitening agent leaks into damaged or cracked tooth fillings.

Reversibility – Whitened teeth can darken again over time. Reducing the intake of certain types of foods and beverages will help reduce staining of teeth.

Alternatives

Alternatives to Naturally White’s Aligner Program include traditional braces, surgical options, and maintaining your current dental condition.

Informed Consent for Aligner Products and Telehealth Services

I understand that Naturally White employees, contractors, and dental professionals involved in my care (“Dental Professionals”) may provide products and services using technology tools, including asynchronous and/or synchronous telehealth technologies (“Telehealth Technology”).

The purpose of this Consent form is to provide essential information about the products offered with Naturally White’s Aligner Program and the use of Telehealth Technology by Dental Professionals to determine if the program is suitable for you. This information will help you make an informed decision about the appropriateness of Naturally White’s Aligner Program and Telehealth Technology for your condition and needs, and fully understand the associated benefits and risks.

Role of the Dental Professional
A licensed Dental Professional will review your medical information, dental impressions or intraoral scans, images, self-reported data, treatment plan, and other relevant information to assess whether the Naturally White Aligner Program, including the use of the aligners, is appropriate for you.

Role of Telehealth Technology
Telehealth Technology offers benefits such as convenience, increased access, and the ability to receive care from home. However, there are risks, including (1) potentially insufficient information for decision-making; (2) interruptions or delays due to equipment or infrastructure failures; and (3) rare events where security protocols may fail, leading to unauthorized access to your health information. Although Naturally White and the Dental Professionals employ security measures like encryption to protect your information, complete privacy and security cannot be guaranteed. You consent to these risks and any other outlined in this Consent form.

Accuracy of Information Provided
To receive quality services, it is crucial that you provide accurate and complete responses to all questions. The Dental Professional will rely on this information to provide appropriate services, and inaccurate information may result in harm or injury. You are responsible for ensuring that the information submitted is always accurate, complete, and current.

Requirements for Participation in Naturally White Aligner Program
By electronically signing this Informed Consent, you acknowledge and agree to the following:

1. You have a treating dentist in your home state who provides regular dental care. You have discussed the Naturally White Aligner Program with your local dentist and had the opportunity to ask questions about clear aligners and the program.
2. Your treating dentist has cleaned, examined your teeth, taken x-rays, and confirmed no periodontal or gum disease in the past 12 months.
3. Your dentist has performed a full oral cancer screening in the last 12 months and confirmed no oral cancer.
4. You have no pain in your teeth or jaws, no loose teeth, and no "baby teeth" with all permanent teeth present.
5. If additional observation by your personal dentist is required, you will make an appointment and re-certify within 30 days, understanding that this may delay your treatment.

Additionally, by electronically signing this Informed Consent, you further represent, acknowledge, and agree to the following:

1. You do not expect the Naturally White Aligner Program to correct any existing bite condition. You understand that while your teeth will become straighter, any preexisting bite condition will remain unresolved, and you may need to seek additional dental advice for bite correction.
2. You fully understand the risks, benefits, and alternatives associated with the Naturally White Aligner Program.
3. You may be required to provide oral consent or other forms of consent in accordance with local state laws in addition to signing this Consent form.

By voluntarily participating in the Naturally White Aligner Program, you acknowledge that dental care is not an exact science, and neither Naturally White nor the Dental Professional guarantees specific results except as expressly stated. You agree to receive services with this understanding.

You have the right to withdraw your consent at any time by sending written notice through the support form at [support form link]. Your withdrawal will be effective upon Naturally White’s receipt of this notice, but will not affect any actions taken before the notice was received. Withdrawal may result in termination of access to certain services from Naturally White and/or the Dental Professional.

By signing this Consent form, you confirm that you have read, understand, and accept all terms set forth.

Agreement to Arbitrate and Class Action Waiver

I affirm that I have read and understand, and have carefully considered, the terms outlined in Naturally White’s attached Agreement to Arbitrate and Class Action Waiver. I agree that any disputes related to Naturally White’s products and services, including but not limited to medical malpractice claims, will be resolved individually through arbitration (and not as part of a class, representative, or collective action) as outlined in the attached Agreement. Lawsuits will not be pursued in any court except for individual claims that fall under Small Claims Court jurisdiction. To initiate arbitration, I must submit a Demand for Arbitration as specified in the Agreement. I agree that arbitration will be conducted by a single, neutral arbitrator chosen by both parties and will follow the rules of the American Arbitration Association.

Exchanges and Returns

If you receive a damaged product, please contact us at [contact information], and we will arrange for a replacement.

For safety reasons, we do not accept returns. Most products are shipped the same day they are ordered. For custom aligners, production begins as soon as you complete your purchase. Once an order is placed, exchanges, returns, or refunds are not permitted.

International Shipping

We ship to all US states. International shipping costs are the customer’s responsibility.

Disputed or Past Due Accounts

Accounts that are disputed or overdue may lead to delayed or discontinued treatment and may void your Naturally White for Life Guarantee™.

Video/Photograph Release

Naturally White’s Aligner Program aims to provide a beautiful smile without surgery or braces. I grant Naturally White, LLC ( “NATURALLY WHITE”) the irrevocable right to use photographs and/or video recordings of me for creating internal Naturally White publications and employee training purposes. These recordings will be used exclusively on internal Naturally White websites and publications, and not on social media or public platforms. The purpose is solely for internal use and training.

I understand and agree that these photographs and/or video recordings may appear on Naturally White’s internal websites and that I may be identified by name or title in accompanying materials. I waive the right to approve the final content. All such media, including photographs, videos, and audio recordings, as well as any reproductions, will remain the property of Naturally White.

I release and discharge Naturally White, its directors, agents, officers, employees, affiliates, and assigns from any claims or liabilities related to the use or distribution of these photographs and/or video recordings, including claims for privacy invasion, likeness appropriation, or defamation.

I confirm that I am at least eighteen (18) years old and competent to contract in my own name, or if under eighteen, that a parent or guardian has signed a parental release form. This release is binding on me and my heirs, assigns, and personal representatives.

Agreement to Arbitrate and Class Action Waiver

By agreeing to this Consent, you acknowledge and accept that any disputes or claims you may have against Naturally White, LLC, or their affiliated dental professionals (collectively "Naturally White et al.")—including but not limited to medical malpractice claims—will be resolved on an individual basis through arbitration, as outlined in this Agreement. This agreement excludes the possibility of bringing any class, collective, or representative actions against Naturally White et al., and also bars participation in or recovery under any current or future class, collective, or representative actions brought against Naturally White et al. by others.

Binding Arbitration Agreement

You and Naturally White et al. agree that any disputes, claims, or controversies related to (a) this Customer Consent, including its existence, breach, termination, enforcement, interpretation, or validity, or (b) your use of the services and products provided by Naturally White et al., whether before or after agreeing to this Consent, will be resolved exclusively through binding arbitration and not in a court of law.

Both parties agree to waive their rights to a jury trial or participation as a class plaintiff or member in any class action or representative proceeding. Unless mutually agreed upon in writing, arbitration will be conducted solely on an individual basis and not as part of a class, collective, consolidated, or representative action. However, either party retains the right to bring an individual claim in small claims court and to seek injunctive or equitable relief in a competent court to address any actual or threatened infringement of intellectual property rights.

Rules and Governing Law

Arbitration will be administered by the American Arbitration Association (AAA) under the AAA’s Consumer Arbitration Rules and Supplementary Procedures for Consumer Related Disputes (the "AAA Rules") in effect at the time, with modifications specified in this Agreement. The AAA Rules can be accessed online or by calling 1-800-778-7879.

The Arbitrator will have exclusive authority to resolve any disputes regarding the interpretation, applicability, enforceability, or formation of this Agreement, including claims that any part of it is void or voidable. The Arbitrator will also address all issues related to the arbitrability of claims, including defenses like waiver or estoppel.

Despite any choice of law provisions in this Consent, this Agreement is governed by the Federal Arbitration Act (FAA), 9 U.S.C. § 1 et seq. The FAA and AAA Rules will override state laws to the fullest extent permitted. If the FAA and AAA Rules do not apply, the laws of California will govern.

Process

To initiate arbitration, a party must submit a written Demand for Arbitration as outlined in the AAA Rules. The AAA provides a form for this purpose online or via phone. The Arbitrator will be selected from the AAA’s roster of consumer dispute arbitrators and will be either a retired judge or an attorney licensed in California. If the parties cannot agree on an Arbitrator within seven days of the Demand for Arbitration, the AAA will appoint one.

Location and Procedure

Unless otherwise agreed, arbitration will take place in your county of residence. For claims not exceeding $10,000, arbitration will be based solely on documents submitted by you and Naturally White et al., unless a hearing is requested or deemed necessary by the Arbitrator. For claims exceeding $10,000, the right to a hearing will be determined by the AAA Rules. The Arbitrator may direct a reasonable exchange of information consistent with the expedited nature of arbitration.

Arbitrator’s Decision

The Arbitrator will issue a decision within the timeframe specified by the AAA Rules. The arbitration award may be entered as judgment in any court with competent jurisdiction. The Arbitrator may only award relief specific to the individual claim and not for broader class or representative claims. The Arbitrator’s decision is final and binding, with no precedential effect. If you win, you may be awarded attorneys’ fees and expenses, as permitted by law. If Naturally White et al. prevails and the claim is found to be frivolous or improperly motivated, Naturally White et al. waives any right to recover attorneys’ fees and expenses.

Fees

You will be responsible for any AAA filing, administrative, and arbitrator fees as outlined in the AAA Rules. However, if your claim does not exceed $75,000, Naturally White et al. will cover these fees unless the Arbitrator finds the claim or relief sought to be frivolous or improperly motivated.

Changes

If Naturally White et al. makes changes to this Arbitration Agreement after you initially agreed, you may reject the changes by providing written notice within 30 days of the change taking effect. This notice must be sent to Naturally White et al. either by mail or hand delivery to our registered agent or by [other specified method]. The notice must include your full name and state your intent to reject the changes. By rejecting changes, you agree to arbitrate disputes according to the provisions of the Agreement as it existed when you first agreed.

Severability and Survival

If any part of this Arbitration Agreement is deemed unenforceable or unlawful, that provision will be severed. The remainder of the Agreement will remain in effect, and arbitration of any remaining claims will proceed as specified. Claims that must proceed on a class, collective, consolidated, or representative basis will be litigated in civil court, with arbitration stayed pending the outcome of individual claims.