Tooth Gem Consent Form

Tooth Gem Consent Form

Thank you for choosing Bling by Bianca!
Name*
Pronouns*
Phone Number*
Email
example@example.com
What gems, design, or placement are you interested in for our session? (Ok to leave blank!)
Please agree to the terms and conditions*

I am aware that there are dental materials used in placing a tooth gem or tooth charm and by signing this document, I release any fault of the person or business placing the tooth gem/charm if this proves to be harmful due to allergic reaction or if there may be any damages or discoloration to the tooth enamel.I understand that a tooth gem/charm can only be placed on a natural surface of the tooth that has no previous dental corrections or materials on it.I understand that tooth gems/charms can only be removed by a dentist or the tooth gem/charm will eventually fall off naturally.I am not allergic to latex glovesI am at least the age of 18 years old, and if am not, I have a consenting parent or guardian present at the time of tooth gem placement.I am aware the tooth gem/charm will last anywhere from 3-12 months, sometimes longer and sometimes shorter depending on my enamel and diet.If the tooth gem/charm* falls off within 4 weeks of initial placement it will be replaced one time at no charge. (* excludes price of gold charm)
Date*

MonthDayYear
Date
Client Signature*

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