Tooth Gems by Shannon

Consent Form
Name

First NameLast Name
Age
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have any of the following?

Severe, persistent, throbbing toothache that can radiate to the jawbone, neck or ear.
Sensitivity to hot and cold temperatures.
Sensitivity to the pressure of chewing or biting.
Fever.
Swelling in your face or cheek.
Tender, swollen lymph nodes under your jaw or in your neck.
Difficulty breathing or swallowing.
Waiver and Consent
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 which might occur to me while I am undergoing this procedure. I release Shannon McCarty and associated shop/convention for any responsibility in case of an accident, illness, or injury.
Photo of your ID
Wanna be tagged on Instagram? List your handle below!
Signature of the Patient
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Waiver and Consent