Tooth Gem Consent Form

First name

Last name

Birthday

Year

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Phone

Address

Do you have any allergies?

Do you have any sensitive teeth?

I authorize the technician to apply tooth gems on tooth #:

I have completed the form to the best of my knowledge and ability. I agree to inform the technician of any changes in the above information. I agree that I do not have any conditions that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow that to adjust accordingly. I agree to waive all liability toward my technician for any injury or damages incurred due to any misrepresentations of my health.

Signature

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I have voluntarily elected to undergo the tooth gem application procedure after the nature and purpose of this treatment have been explained to me.

I understand and acknowledge that there are risks involved with the treatment I will be receiving. Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks and complications, and I have had the opportunity to ask questions regarding these risks and other possible complications.

I understand that the tooth gem must be placed high on the tooth or in the centre because the lower -part of the tooth is what sinks into food when biting.

I understand that once the gem has been adhered there may be some dental adhesive that surrounds the tooth gem on the tooth. I understand that this will wear off within a couple of weeks from normal brushing and eating.

I understand that tooth gems can last anywhere from 3 months to a year and are not meant to be permanent

I understand I should not try to remove my tooth gem myself and should have it professionally removed by a dental professional.

I have to the best of my knowledge given an accurate account of my medical history including known allergies I currently have.

I understand any after care of the tooth gem will be done by my dental professional.

By signing below I agree that I have read and fully understand this agreement and all information detailed above I understand the procedure and accept the risks. I agree I will assume the risk and full responsibility for any and all injuries, losses, side effects or damages that might occur to me while I am undergoing this procedure. I do not hold the technician, Glitter Gaud Hayla Myke, NIKE or Makeway INC. responsible for any of my conditions that were present but not disclosed at the time of this procedure, which may be affected by the treatment performed today.

Signature

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