New York Informed Consent

 

Dental Consent and History for New York

How Do Pop On Veneers Work?

Pop On Veneers are a cosmetic accessory to enhance your smile.  They do not diagnose, treat, cure or prevent a disease. Every Pop On Veneer is unique to each patient.  The process typically takes 1-3 weeks to complete. Feel free to contact Pop On Veneers patient care team to discuss any concerns you may have or to get in touch with your treating dentist.

Your Pop On Veneer treating dentist has asked us to let you know the following:

Pop On Veneer Benefits

  • DISCREET - Pop On Veneers are made of colored, BPA-free plastic. Many people won’t even know you’re wearing them.

  • HYGIENE - Because Pop On Veneers can be removed, you can eat, brush and floss normally, and the process of using Pop On Veneers may improve your oral hygiene habits.

Pop On Veneer Risks

  • TEMPORARY SIDE EFFECTS - You may experience temporary changes in your speech or salivary flow while using Pop On Veneers because of the presence of the removable veneer in your mouth.

  • DISCOMFORT - Your mouth is sensitive, so you can expect an adjustment period and some minor discomfort from having Pop On Veneers in your mouth.  

  • ALLERGIC REACTION - It is possible for some patients to become allergic to the impression materials and or the Pop On Veneers plastic material. If you experience a reaction, please immediately discontinue use and inform your primary care provider and us so that we may advise your treating dentist.

  • CAVITIES, GUM OR PERIODONTAL DISEASE - Cavities, tooth decay, periodontal disease, gingival recession, inflammation of the gums or permanent markings (e.g. decalcification) may occur or accelerate during use of Pop On Veneers. These reactions are more likely to occur if you eat or drink lots of sugary foods or beverages, or do not brush and floss your teeth before inserting the Pop On Veneers, or do not routinely see a dentist for preventive check-ups. In addition, in some circumstances discoloration or white spots may occur; small cavities may increase in size, causing sensitivity and, in some cases, pain or tooth breakage; gingival inflammation may increase, causing soreness and/or bleeding. If underlying periodontal conditions persist unchecked, they may become more prevalent and lead to tooth loss. You may have to discontinue wearing Pop On Veneers. All of these symptoms will require you to seek care from a dentist of your choice.

  • ORAL PIERCINGS - Piercings are contraindicated for impressions. They should be removed before impressions are taken

  • BONDED RETAINER - Bonded retainers, attachments and buttons are contraindications for Pop On Veneers. They should be removed prior to making an impression.  You are also responsible for consulting with your regular dentist regarding the potential consequences of their removal and obtaining, at your expense, all dental care required for their removal. By signing the consent below, you are thereby confirming that you are aware that Pop On Veneers cannot sit over these devices in place and that they must be removed prior to commencing your impression.

  • SAFETY - Pop On Veneers may break, be swallowed or inhaled. You may also have an allergic reaction to the materials used in the Pop On Veneers.

  • BITE ADJUSTMENT - Your bite may change while wearing Pop On Veneers  and may result in temporary discomfort. Your bite may require adjustment after use of the Pop On Veneers.

Healthy Teeth & Gums

Pop On Veneers are most effective if your teeth and gums are healthy. It is your responsibility to routinely see a dentist prior to making your impression and wearing Pop On Veneers, to verify that your teeth and gums are healthy prior to using Pop On Veneers. It is also your responsibility to maintain and have follow-up dental care.

BINDING ARBITRATION & CLASS ACTION WAIVER AGREEMENT

I agree that any and all disputes, claims or controversies directly or indirectly arising out of or relating to this Agreement or any aspect of the relationship between me, on the one hand, and POPONSMILES, LLC  or any of its parents, subsidiaries, related entities, or affiliates, or affiliated dental professionals (collectively "PopOn"), on the other hand, whether based in contract, tort, statute, fraud, misrepresentation or any other legal theory - including, but not limited to, claims relating to my account, PopOn products and services, communications from or on behalf of PopOn, and medical malpractice disputes ("Disputes") - shall be submitted to JAMS, or its successor, for confidential, final and binding arbitration to be resolved by a single arbitrator. I further agree that the arbitration will take place on an individual basis, that class arbitrations and class actions are not permitted, and that I am agreeing to give up the ability to participate in any class action. For avoidance of doubt, I am agreeing to give up the ability to bring a lawsuit in court (except small claims discussed below); and I am giving up the ability to bring or participate in a class action in any form or forum, even if my Dispute is determined not to be subject to arbitration.

I agree that I will send notice of my Dispute to the mailing address below, and that I must wait 30 days after notice is received by PopOnSmiles to initiate arbitration. If I initiate arbitration, I will do so in accordance with JAMS Streamlined Rules for Arbitration ("Rules"). The JAMS arbitrator shall resolve the Dispute and is empowered with the exclusive authority to resolve any dispute relating to the interpretation, applicability or enforceability of these terms or the formation of this Agreement, including the arbitrability of any dispute and any contention that all or any part of this Agreement is unconscionable, void or voidable. Any arbitration conducted pursuant to the terms of this Agreement shall be governed by the Federal Arbitration Act (9 U.S.C.§§ 1-16). The party that prevails in the arbitration shall be entitled to recover from the other party all reasonable attorneys' fees, costs and expenses incurred by the prevailing party in connection with the arbitration; except that this provision shall not apply if I live in California.

The arbitration will be administered by JAMS under its Rules and will comply with the JAMS Consumer Minimum Standards (which are incorporated by reference). Notwithstanding the foregoing, I understand that I may instead litigate a Dispute in small claims court if the Dispute meets the requirements to be heard in small claims court.

I UNDERSTAND THAT I AM WAIVING ANY RIGHT I MIGHT OTHERWISE HAVE TO A TRIAL BEFORE A JUDGE OR JURY. I understand that upon initiating the arbitration in accordance with JAMS rules, I must send a copy of the Demand of Arbitration via U.S. Mail to POPONSMILES, LLC  Attn: PopOn Legal Team, 1530 Antioch Pike, Antioch TN, 37013

I understand and agree that PopOn may, from time to time, amend this Agreement at its sole discretion, to the fullest extent permitted by law, by providing notice of the amendment to the email address that Pop On has for me on file. I understand that any amendments to the Agreement will become effective 30 days after notice is provided by PopOn and shall not apply to any Disputes that have accrued before the date of the amendment.

The formation, existence, construction, performance, and validity of this agreement shall be governed by the laws of the State of Tennessee and the United States, without reference to choice or conflict of law principles.

Informed Consent

TELEHEALTH - I hereby consent to use PopOn's teledentistry platform so that a state-licensed dentist and I can engage in telehealth as part of my order. I understand that "telehealth" includes the practice of health or dental care delivery, diagnosis, consultation, treatment, and transfer of medical/dental information, both orally and visually, between me and a state licensed dental professional who has engaged PopOn to provide certain non-clinical dental support organization services. I further understand and consent to treatment by a state licensed dentist who may be licensed in a state other than my state of residence. 

By signing this Informed Consent, I understand that I am certifying that: During my most recent visit, my dentist has cleaned my teeth and has checked for and repaired cavities, loose or defective fillings, crowns or bridges. My dentist checked my last x-rays or has otherwise verified that I have no shortened or resorbed roots or impacted teeth. My dentist has probed or measured my gum pockets and confirmed that I do not have periodontal or gum disease. My dentist performed a full oral-cancer screening and confirmed that I do not have oral cancer.

I confirm that I do not have pain in any of my teeth or jaws. I further confirm that none of my teeth are loose and my gums are healthy. I further consent to PopOn sharing my personal and medical information with third parties, business associates, or affiliates for the purposes of aligner therapy treatment planning and/or manufacturing purposes.

I certify that I can read and understand English. I acknowledge that neither the dentist prescribing my treatment nor PopOn has made any guarantee or assurance to me. I have read this form and fully understand the benefits and risks listed in this form related to my use of Pop On products. I understand that PopOn contracts with professional corporations which have engaged licensed dentists and orthodontists in the state in which I reside but that the dentist or orthodontist who prescribes and oversees my treatment may be located and licensed in a state other than the state in which I reside. I hereby provide my consent for one or more of the dentists or orthodontists affiliated with that professional corporation including dentists or orthodontists located and licensed in a state other than my state of residence, to review my records for potential evaluation, diagnosis, and treatment. I further understand and consent to PopOnSmiles or such professional corporations seeking second opinions as to my evaluation, diagnosis, and treatment. I understand that neither the dentist who prescribed my treatment nor PopOn can guarantee any specific result or outcome.

I hereby authorize PopOn's use of photographs taken of me, including certain personal health information such as my first name and likeness, for educational and/or marketing purposes, which may result in disclosure to the general public. I acknowledge this authorization is voluntary, I will receive no financial compensation, and my participation in clear aligner treatment does not confer upon me any right of ownership in such photographs. I hereby release PopOnSmiles from any and all liability for any copyright, trademark, or other intellectual property-related claims by me or any third party in connection with my clear aligner treatment. I also understand (i) my treatment is not conditioned on my authorization of PopOn's use of my name or likeness, (ii) I have the right to access, inspect, and receive a copy of any such photograph used by Pop On, and (iii) I can refuse to provide or otherwise revoke such authorization by contacting PopOnSmiles at team@PopOnSmiles.com. This authorization is valid in perpetuity from the date of my consent hereto, unless earlier revoked in the manner prescribed above. I consent to PopOnSmiles contacting my primary dentist to verify dental history or obtain clearance related to my treatment, and to share relevant records as needed for this purpose.

 

Last Updated: 8/13/2026