Tooth Gem Intake and Consent Form

Tooth Gem Intake and Consent Form
General Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Emergency Contact

First NameLast Name
Phone Number
Please enter a valid phone number.
Medical/Dental History

Please answer each question to the best of your ability
Are you currently taking any medications?

YesNo
If yes, please explain
Do you have any allergies?

YesNo
If yes, please explain
Do you have sensitive teeth?

YesNo
By signing below, I agree to the following:
I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward my technician for any injury or damages incurred due to any misrepresentation of my health.
Name

First NameLast Name
Date

MonthDayYear
Date
Signature

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I have voluntarily elected to undergo the tooth gem application procedure after the
nature and purpose of this treatment has been explained to me.
I understand and acknowledge that there are risks involved with the treatment I will be
receiving. Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications, and I have had the opportunity to ask questions regarding these risks and other possible complications
I understand that tooth gems must be placed on a real and flat tooth.
I understand that a tooth that is a false, crowned, or capped is not a good candidate for a tooth gem because the glue will not adhere to a false tooth.
I understand that the tooth gem must be placed high on the tooth, or in the center,
because the low part of the tooth is what sinks into food when biting.
I understand that once the tooth gem is adhered, there may be some dental adhesive surrounding the tooth gem on the tooth. I understand that this will wear off within a couple of weeks from normal brushing and eating.
I understand that tooth gems can last between four months to a year and are not meant to be permanent.
I understand that I should not try to remove my tooth gem myself and should have it professionally removed by a dental professional.
I understand that when my tooth gem falls off naturally, there may still be residual
adhesive left on my tooth.
I understand that if I get my teeth whitened or use whitening strips, the area under my tooth gem will not receive the whitening treatment while the tooth ger is on.
I understand that any aftercare of the tooth gem will be done by my dental professional.
I have, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using
topically.
By signing below, I agree that I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. I agree I will assume the risk and full responsibility for any and all injuries, losses, side effects, or damages which might occur to me while I am undergoing this procedure, I do not hold the technician, whose signature appears below, 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.
Name

First NameLast Name
Date

MonthDayYear
Date
Signature

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Tooth Gem Intake and Consent Form

General Information

Medical/Dental History