Tooth Gem Application - Client History, Release, and Consent Form
Hannah Davis Lashes
First & Last Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
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example@example.com
Mobile Phone Number
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Please enter a valid phone number.
Date of birth
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-
Month
-
Day
Year
Date
Do you wear Invisalign's or any other fitted retainer that would need to go over your Tooth Gem or Gem's?
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Yes
No
Are you currently pregnant or breastfeeding?
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Pregnant
Breastfeeding
Neither
Please list any relevant allergies you have (such as to dental adhesives like etch and/or vitamin E):
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To your knowledge, do you currently have cavities?
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Yes
No
Unsure
Have you had braces removed in the last 6 months?
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Yes
No
Have you had a dental cleaning in the last 6 months to a year?
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Yes
No
Do you have any piercings in your mouth?
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Yes
No
Have you had a Tooth Gem or Gem's before?
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Yes
No
If you answered "Yes" to the question above please tell us when you had the tooth gem applied, if you still have it or when it came off, and if you had any previous sensitivities or allergic reactions during or after application.
Do you have sensitive teeth and/or gums or have you experienced sensitivity in your teeth and/or gums?
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Yes
No
If you answered "Yes to the question above please further explain your sensitivity issues.
By checking "Yes, I understand, agree and accept" I acknowledge that I am purchasing a tooth gem, as a part of the purchase, I am asking for assistance in the application of my tooth gem, and I understand that the tooth gem will be applied by Hannah Davis Lashes and a LED lamp will be used to cure the dental adhesive with the gem to the tooth. RESULTS GUARANTEE: Only natural teeth can benefit from a tooth gem application, I understand that everyone’s teeth are different and that results will vary. I understand that if I have artificial teeth such as caps, crowns, veneers, porcelain, composite, or other restorative material, I CANNOT get a tooth gem on artificial dental work or if I have a fitted retainer such as Invisalign. Also, I am aware that the tooth gem will not damage or harm my natural teeth and that gems should only be placed on natural teeth.
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Yes, I understand, agree and accept
By checking "Yes, I understand, agree and accept" I acknowledge and understand the POTENTIAL RISKS: Although tooth gem applications are generally safe, I understand that some of the potential complications of this application include, but are not limited to: GUM/LIP IRRITATION/ALLERGIC REACTION: Dental adhesives that come in contact with gum tissue or the lips during the treatment may cause inflammation or irritation of these areas. This is due to inadvertent exposure of small areas of those tissues to the dental adhesive. The inflammation and/or irritation of the gums and lips are transient, and the change of the gum tissue will reverse within 30 minutes. I may feel a stinging and tingling sensation on these soft tissues if the adhesive comes in contact with then. If the sensation doesn’t go away I am to seek medical attention as this may be an allergic reaction. TOOTH SENSITIVITY: If a tooth gem is placed on a tooth with existing sensitivity, micro-cracks, open cavities, leaking fillings, exposed roots, or other dental conditions that cause sensitivity, you may find that those conditions increase or prolong tooth sensitivity after the gem application. TOOTH DECAY: If you have poor oral hygiene and are not brushing around the tooth gem, although uncommon, it is possible for particles to get stuck and lead to unwanted tooth decay. CAN BE SWALLOWED: Our tooth gems have no sharp edges and are small in diameter. If swallowed they will come out later on the natural way.
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Yes, I understand, agree and accept
By checking "Yes, I understand, agree and accept" I acknowledge the ELIGIBILITY: I understand that this treatment CANNOT be used by people with gum disease, open cavities, leaking fillings, fitted retainers such as Invisalign, or other dental conditions, or people with a known allergy to etch material and/or to dental adhesives. I understand people under the age of 18 must have parental/guardian permission to have a tooth gem application. People that have had braces removed should wait 6 months for cement residue to wear off before getting a tooth gem. If I feel a sharp pain on a particular tooth during the treatment I should stop the treatment and contact my dentist since this could be a sign of a cavity. I understand I can not eat for a minimum of 2 hours after application, I may only drink plain water, and I can only eat soft foods for the first 24 hours after application. I also understand I cannot brush or floss my teeth for 12 hours with a regular toothbrush and 24 hours with an electric toothbrush after application. I am aware that I am not in a dental office and that the staff here present are neither a dental professional or a dentist. We do not offer any advice on oral health. It is important to visit your dentist on a regular basis. I understand that liability is limited to the amount paid for my tooth gem product and that the management, staff of this establishment assume no liability of any kind. I understand it is recommended that I visit my dentist if I experience any problems after my tooth gem application. By signing this document, I indicate that I am not ineligible as per the criteria listed above, that I have read and fully understand this entire document including the possible risks, complications and benefits that can result from the treatment, and I am performing this treatment under my own responsibility. I also certify that I HAVE HEALTHY TEETH AND GUMS.
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Yes, I understand, agree and accept
What is the current date you are filling out this form?
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Month
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Day
Year
Date
By signing here you are acknowledging that you agree, understand, and accept the contents of this form. You also acknowledge that you are giving permission to allow a minor to have the service of Tooth Gem application done. (Please sign below - Parent or guardian if under 18 years of age.)
By signing here you are acknowledging that you agree, understand, and accept the contents of this form (Please sign below - Individual having the service done.)
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Submit
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