Tooth Whitening Research
Internet registration form
Terms & Conditions
The candidates have to attend the first session for clinical screening to ascertain that they are qualified for the whitening research.
The chosen subjects should follow strictly the instructions given to them.
Candidates should be willing to attend appointment sessions and follow ups once every 3 months for a period of 2 yrs from the start of the research.
No other whitening products or procedures should be employed by the subject once the research has begun and for a period of 2yrs duration until the research is completed.
Personal Information
Name
*
Age
years
*
Gender
Male
Female
*
Nationality
*
Civil ID
*
Home Telephone
*
Mobile Telephone
*
Email address
Details
1) Present tooth color
Yellow
Brown
Blue
2) Have you done any whitening Treatment before?
*
Yes
No
3) Please select whichever is applicable
Diabetes
Active gum disease
Smoking
Decayed teeth that are not filled or restored
Crown/Bridges on front teeth
Pregnant/Lactating (for women only)
Heart Problems:
Allergy:
4) How many times a day do you brush your teeth?
*
5) Do you use any mouthwashes? If yes, please specify
* Required fields.
Note: The qualifying candidates shall be notified by e-mail or phone.