GYPSY TATTOO COLLECTIVE - Tooth Gem Consent Form

Tooth Gem Consent Form

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I First Name* hereby declare that I give * full consent to apply gem jewellery to my teeth and that all the information given is true to my knowledge.
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Do you have any allergies? If yes please specify*

YesNo
Please specify
Any ongoing dental conditions? (Tooth decay, gum disease, etc if yes specify*

YesNo
Please specify
Have you recently had a mouth abscess or ulcer?*

YesNo
Do you suffer from oral herpes?*

YesNo
Do you have any veneers/caps installed?*

YesNo
Do you wear any retainers?*

YesNo
I confirm I am at least 18 years of age*

YesNo
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I understand that this is a temporary procedure that can last anywhere between one month to one year and ONLY a professional Dentist can safely remove the gem from the tooth. I understand I am solely responsible for any and all costs associated with professional removal procedures and or cleaning. I agree to follow the pre and post treatment instructions given and understand that failure to do so may result in teeth/gum damage as well as less longevity of the bonded gem itself. I understand that this is a non invasive procedure that involves a gem (Glass, Crystal or Solid Gold) being bonded to the enamel of the natural tooth with the use of professional bonding agents. I understand that Gypsy Stables does not offer refunds for thisprocedure*

YesNo
Please draw on the picture below which tooth you’d like to have gems applied*
Name*

First NameLast Name
Date of birth*

MonthDayYear
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
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Piercer Signature - Please let the piercer review the information and sign before submiting the form*

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Tooth Gem Consent Form

Please SELECT to indicate your answer

Please SELECT to indicate your answer