TOOTH GEM CONSENT, RELEASE OF LIABILITY AND WAIVER OF ALL CLAIMS

Please read the following and initial each provision on the line provided to show that you understand and agree to the provision. In consideration of both (a) Receiving a tooth gem, gold gem or similar tooth gem product from the Tooth Gem Technician and (b) the use facilities provided by Iced Smiles and its employees, you agree to the following:

• I,   {input9:3}       certify that this informed consent, and waiver form was completed by me and that I understand all the questions, terms and conditions, and all entries in it and information are true and completed to the best of my knowledge. I agree to observe and obey all posted, written, and verbal rules and warnings including on those materials provided by the studio.

 

• I agree to waive and release to the fullest extent permitted by applicable state law each of the Tooth Gem Technician, all employees, contractors, and the management of the studio from all liability whatsoever, for any and all claims or causes of actions that I, my estates, heirs, executors or assigns may have for personal injury or otherwise, including any direct or consequential damages, which result or arise from the application of, or my accidental swallowing of tooth gems, weather caused by the negligence or fault of the Tooth Gem Technician. {initial}

 

• I am 16 years or over. {initial}

If underage parental approval is required: Please be advised.

•  I understand that the application of tooth gems and products does not included drilling into the tooth or breaking skin and may cause marks or discoloration of my teeth. {initial}

 

• I understand that the application process of tooth gem may affect my tooth enamel, and I have been given the opportunity to talk about the risk associated with my tooth gem products with my Tooth Gem Technician. {initial}

 

• I understand that the bonding agent used to apply my tooth gem may affect my teeth, and that I have been given the opportunity to talk about the risk associated with the bonding agent with my Tooth Gem Technician and dentist. {initial}

 

• I understand and agree that the tooth gem application procedure is semi-permanent and there is no guaranteed amount of time that the product will stay on my teeth. {inital}

 

• I understand that certain tooth gems may fall off for any or no reason after applying the gems to my teeth. I understand and agree that Iced Smiles is not responsible for replacing or substituting any products, including any gems, diamonds, gold pieces, if my tooth gems fall off. {initial}

 

• I understand that I should continue to see a dentist regularly to maintain proper oral health and hygiene for my teeth. {initial}

• I have been advised that I should contract a dentist to remove all residue from the bonding agent from my tooth if my tooth gem falls off or if I wish to remove it. {initial}

 

• I am currently NOT pregnant. {initial}

Please notify your technician before your session if you are pregnant to know the risks.

• I am over the age of 18. {initial}

If you are underage please have a Parent/Guardian present with a driver's license to proceed. Also, please fill information below.

11. I understand and will follow the aftercare instructions given to me by the Certified Tooth Gem Technician to ensure the longevity of my tooth gem. {initial}