Tooth Gem Consent Form
Client Information
Name
*
First Name
Last Name
Pronouns
He/him
She/her
They/them
Other
Phone Number
*
Format: (000) 000-0000.
Email
*
example@baronart.tattoo
Birthdate
*
/
Month
/
Day
Year
I am 18+ years old
*
Yes
No
Attach a copy of your legal ID (military ID cannot be accepted)
*
Client ID
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Choose a file
I am the person on the legal ID presented as proof that I am at least 18 years of age or I am with a legal guardian.
Cancel
of
Attach a copy of the legal guardian's legal ID (military ID cannot be accepted)
*
Guardian ID
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Consenting legal guardian is present and is the person on the legal ID presented.
Cancel
of
Attach a copy of the minor's birth certificate or proof of guardianship.
*
Proof of Guardianship
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Names on documentation must match attached IDs.
Cancel
of
Pre-Procedure Questionnaire
Do you have any conditions/communicable diseases or take any medications that may affect the body art procedure or healing process?
*
Do you have any history of herpes infection, diabetes, allergic reaction to latex or antibiotics, hemophilia, or other bleeding disorder or cardiac valve disease?
*
Yes
No
Have you taken antibiotics within the past two weeks?
*
Yes
No
Do you have any medical conditions/communicable diseases?
*
Asthma
Blood thinners
Diabetes
Eczema/Psoriasis
Epilepsy
Faintness or dizzy spells
Heart condition
Hemophilia
Hepatitis
Herpes
HIV
Infections
Pregnant/Nursing
Prophylactic antibiotics
Rashes
Scarring/Keloiding
None
Other
Do you take any medications?
*
Yes
No
Please list medications.
Are you currently under a doctor's care for a continuing condition?
*
Yes
No
Do you have any conditions that may affect the application of tooth gems?
*
Yes
No
Please list conditions.
Acknowledgment and Waiver
Please check all boxes below to agree.
*
I am not under the influence of alcohol or drugs and I am voluntarily submitting to this tooth gem procedure without duress or coercion.
*
I understand that the application process of tooth gems and bonding agent may affect my tooth enamel.
*
I understand that the tooth gem application procedure is semi-permanent and there is no guaranteed amount of time the products will remain on my teeth.
*
I understand that false, crowned, or capped teeth are not suitable for tooth gems because the gems will not adhere properly.
*
I understand that tooth gems may interfere with use of retainers/mouth guards and wearing them may reduce the retention rate.
*
I understand that it takes 24 hours for the bonding agent to fully cure.
*
I understand that I should not eat or drink anything except for water for four hours following the tooth gem procedure. The gem bond may be weakened by acidic compounds.
*
I understand that I should only eat soft foods for 12 hours.
*
I understand that I should avoid candy and gum.
*
I understand that I should avoid smoking or vaping for 12 hours following the tooth gem procedure.
*
I understand that I should not play with my tooth gems with tongue or fingers.
*
I understand that I should not brush teeth with gems applied for 12 hours, I should only brush my teeth with a soft bristle brush, and I should also avoid using electric tooth brushes on teeth with gems applied.
*
I understand that I should not bleach or perform blue light whitening procedures on my teeth because such procedures may affect the bonding agent and the gem itself.
*
I understand that I should continue to see a dentist regularly to maintain proper oral health and hygiene for my teeth.
*
I understand I should contact a dentist to remove all residue/bonding agent from my teeth if my tooth gem falls off or if I wish to remove it.
*
I agree to follow all instructions concerning the care of my tooth gem.
*
I agree to read and follow the aftercare instructions below.
Tooth Gem Aftercare
The First 24 Hours After Application
Don’t eat or drink anything except for water for four hours. The gem bond may be weakened by acidic compounds.
Only eat soft foods for 12 hours.
Avoid acidic drinks, soda, coffee, and tea for 12 hours.
Avoid smoking or vaping for 12 hours.
Don’t brush teeth with gems applied for 12 hours.
General Care
Brush your teeth with only soft bristle toothbrushes.
Continue to see a dentist regularly to maintain proper oral health and hygiene for my teeth.
Contact a dentist to remove all residue/bonding agent from my teeth if my tooth gem falls off or if I wish to remove it.
What to Avoid
Eating candy and gum or any other hard/sticky food.
Playing with your tooth gems with tongue or fingers.
Brushing tooth gems with electric toothbrushes.
*
I understand that Baron Art Tattoo is not responsible for replacing or substituting any gem products. Complementary replacements may be offered for gems that fall off within one week of tooth gem procedure.
*
I understand that refunds are not offered for services rendered.
*
I understand that any products that have been placed on a tooth are final sale and cannot be exchanged or refunded. This includes products that have not been bonded yet.
*
All questions about the tooth art procedure have been answered to my satisfaction and I have had the opportunity to talk about risks with my tooth gem technician and dentist.
*
I indemnify and hold harmless Baron Art Tattoo and its employees against any claims, expenses, damages, and liabilities.
*
I wish to proceed with this tooth gem procedure and I assume any and all risks that may arise from this procedure.
*
I acknowledge should any part of this document be construed as illegal then that part shall be void and the rest shall be held in force as if that part did not exist.
*
I certify under penalty of perjury that the above information is true and correct.
Client Signature
*
I have read and agree to the above consent form.
Guardian Signature
*
I have read and agree to the above consent form.
Submit
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