Tooth Gem Consent Form
Thank you for choosing Bling by Bianca!
Name
*
Pronouns
*
Phone Number
*
Format: (000) 000-0000.
Email
example@example.com
What gems, design, or placement are you interested in for our session? (Ok to leave blank!)
Dental & Medical History: Check all that apply
Allergies to metals (including Nickel), adhesives, composites, acrylics, or latex.
Photosensitivity or light-triggered medical conditions (e.g., epilepsy, lupus, or taking medications that cause light sensitivity).
Current orthodontic treatment (Braces, Invisalign, or clear retainers—gems cannot be placed under aligners or on brackets).
Artificial tooth surface in the desired placement area (Veneers, crowns, or implants. Can’t guarantee longevity on non-enamel).
Gum disease, gingivitis, or compromised enamel (Decay, decalcification, or current tooth pain).
Recent dental surgery or professional teeth whitening in the last 14 days.
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 the technician, the business, and its staff from any and all liability, claims, or damages related to this procedure, including any dental bills incurred for the removal of the gem or repair of the tooth..
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 understand that if I do not maintain excellent oral hygiene, plaque can build up around the gem, which carries a risk of tooth decay or enamel damage.
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)
I 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 have truthfully disclosed my relevant medical and dental history.
Date
*
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Month
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Day
Year
Date
Client Signature
*
Submit
Should be Empty: