Tooth Gem Consent Form

TOOTH JEWELLERY CONSULTATION FORM
Before we start, you need to fill out a short medical form in order to make your treatment as effective and safe as possible. Please note that all information is strictly confidential.
Name (Must match ID)*

First NameLast Name
Preferred Name
Pronouns
Age *
Date of birth*

DayMonthYear
Date
Contact Number *
Email Address *
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Allergies
DO YOU HAVE, OR HAVE YOU RECENTLY BEEN AFFECTED BY ANY OF THE FOLLOWING?

Please let us know as for your safety, we may not be able to go ahead with your service today
Abscess or ulcerFresh lip filler or oral piercingOngoing dental problemsFalse Teeth/veneers.Pregnant/breastfeedingInvisalign/retainerHalitosisOral HerpesRecent dental surgerySensitive teethPrevious filling on the front of the tooth
If you have composite bonding tooth gems on those teeth are VERY hit and miss, by clicking the below you understand this may result in a reduced longevity.

I do not have composite bondingI have composite bonding and understand
WITHIN THE LAST 48 HOURS, HAVE YOU EXPERIENCED ANY VOMITING, DIARRHOEA OR ANY FORM OF VIRUS OR INFECTION? YES / NO*

YesNo
I confirm that I am of sound mind and agree to follow the aftercare provided. I understand that my tooth gem can last anywhere from one month to one year depending on how well I look after them and to achieve longevity I must follow the aftercare.*

Confirmed
I understand that while given a two week grace period, any adhesive remaining on the tooth is the result of improper aftercare and will need a scale and polish to remove. This will be at the client's expense.*

Confirmed
I allow my tooth gem to be photographed and for those images to be used on my tooth gem technician's, High Hopes & Loosefest's website and social media accounts.*

Confirmed
I acknowledge High Hopes, Loosefest & Crystal Canine do not offer refunds.*

Confirmed
I indemnify and hold harmless High Hopes, Loosefest, Crystal Canine and my tooth gem technican against any claims, expenses, damages, and liabilities*

Confirmed
I understand that by going ahead with treatment all information provided is correct and I am going ahead at my own discretion.*

Confirmed
I understand that by going ahead with treatment, I confirm that I am of sound mind and that all information provided is correct and I am going ahead at my own discretion.*

Confirmed
Client Signature *

Clear
Date

DayMonthYear
Date
Please upload a copy of your ID (passport or driving license)*

Cancelof
Should be Empty:

TOOTH JEWELLERY CONSULTATION FORM

DO YOU HAVE, OR HAVE YOU RECENTLY BEEN AFFECTED BY ANY OF THE FOLLOWING?