TOOTH GEM CONSENT FORM

TOOTH GEM CONSENT FORM
Name

First NameLast Name
DATE

MonthDayYear
PHONE NUMBER
Format: (000) 000-0000.
PLEASE READ OVER AND CHECK ALL THAT APPLY:
By signing this document, I release the fault of the person or the business placing the tooth gem if this proves to be harmful due to an allergic reaction or if there is any discoloration or damages to the tooth or the enamel.
SIGNATURE
DATE

MonthDayYear
Should be Empty: