1. I 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 complete to the best of my knowledge. I agree to observe and obey all posted, written and oral rules and warnings, including those materials provided.
2. I agree to waive and release to the fullest extent permitted by applicable state law the Tooth Gem service provider and Thompson Tattoo from all liability whatsoever, from any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, including any direct or consequential damages, which may 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 service provider.
3. I am 16 years old or over.
4. I understand that the application of tooth gems and products does not include any drilling into the tooth or breaking skin and may cause marks or discoloration of my teeth.
5. I understand that the application process of tooth gems may affect my tooth enamel, and I have been given the opportunity to talk about the risks associated with my Tooth Gem products with my Tooth Gem service provider.
6. 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 risks associated with the bonding agent with my Tooth Gem service provider.
7. I understand and agree that the tooth gem application procedure is semi-permanent and there is no guaranteed amount of time the products will remain on my tooth.
8. 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 Thompson Tattoo is not responsible for replacing or substituting any products, including any gems, white gold, crystal or gold charms, if my tooth gem falls off.
9. I understand that I should continue to see a dentist regularly to maintain proper oral health and hygiene for my teeth.
10. I have been advised that I should contact 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.
11. I understand and will follow the aftercare instructions given to me by the Tooth Gem service provider to ensure the longevity of my tooth gem.
12. I have been advised to not bleach or perform blue light whitening procedures on my teeth because such procedures may affect the bonding agent used to apply my tooth gem and the tooth gem itself.
13. I agree to indemnify and defend Thompson Tattoo and its 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 facilities of Thompson Tattoo.
14. I hereby authorize my Tooth Gem service provider and Thompson Tattoo permission to take photographs and use my likeness in a photograph or video for its promotional materials and publications, print and digital. I understand and agree that all rights to any photograph of me belong to 404LTR. If you do not authorize permission to take and use your photos, you must speak to our technician before the service is rendered.
15. The invalidity or unenforceability of any provision of this Release of Liability shall not have any effect on any other provision of this Release of Liability or of any other applications of such provision, and such unenforceable provision shall be deemed not to be a part of this Release of Liability.
16. The parties will attempt to resolve any dispute arising out of or relating to this Release of Liability through friendly negotiations. If the matter is not resolved, the parties agree to using mediation.
I HAVE READ THIS DOCUMENT AND UNDERSTAND ITS CONTENTS. I FURTHER UNDERSTAND THAT BY SIGNING THIS RELEASE OF LIABILITY, I VOLUNTARILY SURRENDER CERTAIN RIGHTS. 404:LTR AND THOMPSON TATTOO IS NOT RESPONSIBLE FOR ANY DAMAGE CAUSED BY THE TOOTH GEM APPLICATION.