Tooth Gem Informed Consent Form & Liability Waiver

Name:

First NameLast Name

Email:

example@example.com

Phone Number:

Please enter a valid phone number.

Are you a client or model?

To register for model openings please visit MarisGoddessEffects.com/models *Please note model services are completed by students under instructor’s supervision.

How did you hear about our salon?

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 gem 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.

Signature*

Printed Name*

Date*

Date

Please print or screenshot the aftercare attached for your records.

TOOTH GEM INFORMED CONSENT FORM & LIABILITY WAIVER