Tooth Gem and/or Whitening Consent Form

Please read the following and initial each provision to show that you understand and agree to the statement. In consideration of both receiving a tooth gem, charm, or similar tooth gem product from the technician, as well as use of the Black Rose facilities, you agree to the following:

I certify that this informed consent and waiver form was completed by me and I understand all of the questions terms and conditions, and all entries in it and information are true and complete to the best of my knowledge. I agree to observe and obey all posted, written, or oral rules and warnings, including those materials provided by the studio.I agree to waive and release to the fullest extent permitted by applicable state law each technician at Black Rose from all liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors or assigns may have from personal injury or otherwise, including any direct or consequential damages which result or arise from the procedure whether caused by the technician, or negligence or fault of aftercare.I am 18 years old or over.I understand the application of tooth gems and similar procedures does not include any drilling into the tooth or breaking skin, but may cause a change in shade of the tooth.I understand that the whitening or gem process may affect the tooth enamel, and have been given the opportunity to discuss risks of sensitivity associated with the procedure.I understand and agree that this process is semi permanent, and results depend on aftercare. Everyone’s teeth are different, and Black Rose has no guarantee that the procedure will produce desired results.I understand that certain tooth gems can fall off for no reason. I understand that Black Rose is not responsible for replacing or substituting any products if the gem falls off.I understand that I should continue to see my dentist regularly to maintain proper oral hygiene for my teeth.I have been advised to contact my dentist for any residue remaining on the tooth after the gem falls off if the glue does not come off naturally within a few weeks, or if you want to remove the gem before it falls off.I agree to indemnify and defend the studio and Black Rose Cosmetics owners, representatives, employees, contractors, and agents, against all claims, causes of action, damages, judgements, costs or expenses, including attorney fees and other litigation costs, which may in any way arise from my use of or presence upon the studio.

I have read this document and understand its contents, I further understand that by signing this release of liability, I understand that Black Rose Cosmetics is not responsible for any damage caused by the procedure process.

Client's Name*

First NameLast Name

Email

example@example.com

Client's Signature*

Birthdate*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date Signed*

Date