Tooth Gem Consent Form
Patient Information
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health and Dental Information
Toothpaste Brand
Are you using Dental floss in cleaning your teeth?
Please Select
Yes
No
Do you have any allergies or sensitivities to dental materials?
Yes
No
Do you have any false, crowned, or capped teeth or veneers?
Yes
No
Are you using braces?
Please Select
Yes
No
Do you have tooth filling?
Please Select
Yes
No
Do you have any known tooth decay or broken teeth?
Please Select
Yes
No
Do you have any allergies?
If yes, then please specify it on the field above.
Are you currently taking any medications?
If yes, then please specify it on the field above.
Do you have any medical conditions that we should be aware of? (Communicable disease, cardiovascular problems, diabetes, etc.)
If yes, then please specify it on the field above.
Waiver and Consent
I authorize Haus of Remedy to perform this procedure. I have indicated that I have no conditions that would negatively effect the outcome of my service.
I release Haus of Remedy for any responsibility in case of an accident, illness, or injury.
I authorize Haus of Remedy the right to take edit, alter, copy, exhibit, and make use of any and all pictures, video, and or audio taken of me to be used for promotional purposes on all social media platforms.
I acknowledge that all information I provided in this form is true and accurate.
I understand that took gems must be placed on a real, and flat tooth.
I understand that some dental adhesive may appear around the tooth gem and surrounding area. The excess dental adhesive will wear off within a few weeks from normal brushing and eating.
I understand that a tooth that is false, crowned, or capped is not a good candidate for a tooth gem because the glue will not adhere to a false tooth.
I verify that I read and understood the above statements and agree to them. I understand the procedure and accept the risks. I do not hold Haus of Remedy responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today.
Signature of the Patient
Date Signed
-
Month
-
Day
Year
Date
Submit
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