Tooth Gem Consent Form

Piercer Name

Full Name*

First NameLast Name

Preferred Name

First NameLast NamePronouns

Age*

Date of Birth*

Date

Phone Number*

Area CodePhone Number

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

I hereby give consent to Zen Ink, LLC to install tooth gem(s), and in consideration of doing so, I hereby release and forever discharge and hold harmless Zen Ink, LLC, the Piercer/Artists and all affiliates, Owners, Managers and Independent Contractors from any and all claims, damages or legal actions arising from or connected in any way with my procedure and conduct used in my performing my procedure, to the fullest extent allowed by the law.*

YesNo

I fully understand that any Independent Contractors of Zen Ink, LLC when performing a tooth gem procedure, do not act in the capacity as a medical professional. The suggestions made by any Independent Contractors or agent of Zen Ink, LLC are just suggestions. They are not to be construed as, or substituted for advice from a medical professional. I understand that the tooth gem procedure will be performed using appropriate techniques and instruments.*

YesNo

I understand that I am making a modification to my body, and no claims about the possibility of reversing these changes have been made or implied by Zen Ink, LLC or any of its Independent Contractors or agents. I agree that these waivers also pertain to and are designed to protect any and all establishments of Zen Ink and their Independent Contractors.*

YesNo

I am at least 18 years old.*

YesNo

I understand that the gem and bonding agents may cause an allergic reaction when placed or swallowed, causing redness and swelling of the tissue, pain, itching, vomiting or severe allergic reactions.*

YesNo

I understand that the gem may contain some less as in all glass/crystal/metallics*

YesNo

I understand that this procedure is temporary and on average a gem lasts four months*

YesNo

I understand that the gem is bonded to the enamel.*

YesNo

I understand that if I want to remove the gem I will have to go to a dentist and I am responsible for all costs associated with removal/cleaning*

YesNo

I understand that if I whiten my teeth or stain my teeth while wearing the tooth gem that the area beneath the gem will be a different color and I accept all costs associated with corrections*

YesNo

I understand that if the gem(s) fall off that I am solely responsible for the cost of replacing them or removing any adhesive that may be remaining*

YesNo

I agree that the tooth/teeth I am getting the gems placed on is a real and flat tooth/ teeth - If you have a tooth that is a false, crowned, or capped the Tooth Jewel glue will not adhere to the false tooth.*

YesNo

I authorize ZEN INK to apply a Tooth Jewel with Dental Adhesive to my tooth/teeth and that this/these teeth are real.*

YesNo

Do you have any medical conditions that we need to be aware of?*

YesNoOther

Are you pregnant/breastfeeding?*

YesNoOther

Do you have sensitive teeth?*

YesNo

I agree to speak softly and silence my cell phone in order to help keep a calm, spa like environment.*

YesNo

Are you currently sick? In the last 14 days, have you been sick or been in contact with anyone that is sick.*

YesNo

I understand the Zen Ink has put additional protective measures in place in order to reduce the risk of contamination, virus, or pathogen but it is impossible to completely eliminate that risk.*

YesNo

I agree to release and forever hold harmless Zen Ink and its agents and representatives for any and all claims, damages, or legal actions in the event I contract COVID-19 or any other illness after choosing to get a procedure.*

YesNo

Have you experienced any symptoms (fever, cough, shortness of breath, chills, body aches, sore throat), had exposure to someone exhibiting COVID-19 symptoms or confirmed illness within the last 14 days, or have you traveled internationally?*

YesNo

I consent to Authorization for Picture of my tooth gem to be used on Social Media, Website etc*

YesNo

Are you allergic to any of the following?*

LatexDental MaterialsNONEOther

I have read this release form and confirm that all the information I have given is correct. I understand that this is a release form and I agree to be legally bound by it.

I understand there are no refunds.

I confirm that the information I provided in this document is accurate and true.

Signed Date*

Date

Client Signature*

Please take a picture of your Drivers License or Passport*

For Minors:

Parent must be present at time of procedure. We will also need proof of parenthood at time of procedure. This will be something that says you are the parent/legal guardian. Examples are: Child and parent IDs with matching last names and addresses, Birth Certificate and Parent ID, Court Issued paperwork and ID.

Parent Signature

Photo of any additional documentation (for minors only)

Client Information

Acknowledgment and Waiver