Teeth Whitening - Tooth Jewel Application Release Form

Name

Email

example@example.com

Contact Number

Please enter a valid phone number.Format: (000) 000-0000.

Social Media Handle

@MinksMonthly @NotYourAverageEsthetics

Birth Month

How did you hear about us?

Dentist's Name

Dentist's Address

Emergency Contact

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Do you have any allergies to dental materials? (YES) (NO) If so, what

Do you have sensitive teeth ?

Is the tooth you want your Tooth Jewel on REAL (Not crowned, false, or capped)?

Which Tooth/Teeth do you want the gem to be applied on ?

Tooth Jewel Placement: Tooth Jewels must be placed on a real and flat tooth, so please choose tooth/teeth 1, 2, 3, 4, 5, 6, 7, or 8 from the picture above. If you have a tooth that is a false, crowned, or capped the Tooth Jewel glue will not adhere to the false tooth. The Tooth Jewel must be placed high on the tooth, or in the center, as the low part of the tooth is what sinks into food when biting.

Tooth Jewel General Information and Care: Tooth Jewels are non-invasive; they don't damage the tooth or enamel and are semi- permanent. The adhesive is the same as what a dentist uses to put on braces. The Tooth Jewels we use are 100% lead free Swarovski Crystal. Once the Tooth Jewel is on, there may be some dental adhesive surrounding the Tooth Jewel on the tooth. This will wear off within a couple of weeks from normal brushing and eating. Tooth Jewels can last anywhere between four months to a year. If you are ready to remove your tooth jewel before it naturally falls off, it can easily be removed at your next professional routine dental cleaning. Once your tooth jewel does fall off naturally, there may still be some residual adhesive left on your tooth. This too can easily be removed at your next professional routine dental cleaning. If you use tooth whitening strips, the area under the Tooth Jewel will not receive the whitening treatment while the Tooth Jewel is on. Tooth Jewel Replacement Guarantee: If your tooth gem falls off within four months of us applying it, you may bring in your original receipt along with your copy of this signed form and we will be happy to apply another for you. We are only able to replace the tooth jewel once. and its employees are not responsible for any damage done to your tooth/

Agreement: You understand that the Tooth Gem Specialist and company are not responsible for any damage done to your tooth/teeth during or after the Tooth Jewel procedure. Any after care of the Tooth Jewel will be done by your dental professional.

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

Client initials

Thank you giving us the time to get to know YOU & signing the Consent form, its much appreciated towards your lash experience!

By signing below, I fully understand what I have read and I am of sound mind and capable of executing this form and wish to receive services from Tommara Anderson. I verify that I have read and understand the above statements, I agree to have answered medical questions honestly to the best of my knowledge and acknowledge that it is the client’s responsibility to inform the esthetician of any changes in health or skin care that could affect the outcome of the procedure .By signing below, I verify that I have read and understand that this agreement remain in effect for the procedure and all future procedures conducted by my technician until December 31 . I understand that this agreement is binding and that I have read an fully understand all information listed above. I represent that I am over the age of 18 years. If below 18 years of age a parent or guardian must also sign this form.

Customer Signature

Date

After Care Instructions for Tooth Jewels:

Do not touch or play with the crystal with your tongue or finger.
You may feel the crystal inside your lips for the first few days but should get used to it after that.
Do not eat or chew gum for one hour after the Tooth Jewel is placed.
When you eat for the next 12 hours, softer food is better.
You can drink and smoke immediately after the Tooth Jewel is placed.
Do not brush your teeth you 12 hours after the Tooth Jewel is placed.