Tooth Gem Consent and Liability Waiver

Client Intake Form- Cosmetic Tooth Jewerly

This form is completely cofidential. Completion of this form assists the technician in providing the best treatment for you
Personal Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
D.O.B
How did you hear about us?
Reason for Tooth Gems?
Dental information
Have you had tooth gems before?

YesNo
Do you have sensitive teeth?

YesNo
Do you have any fillings?

YesNoFront of TeethBack of Teeth
Do you have any known untreated dental issues or worn teeth?

YesNo
Do you have crowns, veneers, bridges or any other type of restorations

YesNoFront of TeethBack of Teeth
Do you have any sores in or outside of your mouth?

YesNo
Do you visit your dentist for regular cleanings/check-ups?

YesNo
Medical Information
Do you have any allergies?

YesNo
If yes, please explain:
Are you Allergic to:

LatexOther
If yes, please explain:
Please initial the following:
Signature I have voluntarily elected to undergo the tooth gem application procedure after the nature and purpose of this treatment has been explained to me.
Signature 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
Signature I understand that tooth gems must be placed on a real and flat tooth
Signature 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.
Signature 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.
Signature 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.
Signature I understand that tooth gems can last between two months to a year and are not meant to be permanent
Signature I understand that I should not try to remove my tooth gem myself and should have it professionally removed by a dental professional.
Signature I understand that when my tooth gem falls off naturally, there may still be residual adhesive left on my tooth.
Signature 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.
Signature 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.
Signature I understand that any aftercare of the tooth gem will be done by my dental professional.
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. 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

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Customer Signature
Signature

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Parent/Guardian Signature
Date

MonthDayYear
Date

Client Intake Form- Cosmetic Tooth Jewerly

Dental information

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