Tooth Gem Consent Form

Tooth Gem Consent Form
Client Name*

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Date
Do you have any allergies?*

YesNo
If yes, what are they
Do you have gum disease, gingivitis or sensitive teeth?*

YesNo
If yes what:
Do you wear a removable appliance? Tick all that apply.

Mouth guard (sports)Night guard (for grinding/clenching)Retainers (orthodontics)GrillzOther- including dentures
Do you have any dental concerns that we should know of? including tooth sensitivity, fillings, grinding/clenching, bleeding gums, tooth decay, crowding, etc. *
Medical History
Are you or do you think you might be pregnant?

yesno
Are you breastfeeding at the moment

yesno
Are you currently taking MEDICATION (including natural supplements)? If yes, please list:
Please tick

smokernon smokerex smoker
Have you ever had Professional Teeth Whitening Therapy/Treatment before?

yesno
Are you experiencing any of the following?*

Sensitive TeethLoose TeethLost filling / cavityBleeding gumsDry mouthDiscoloured teethTooth painPain in face / jawWorn or broken teethGrinding / clenchingGum recessionnone of the above
Authorization
Please write the numbers where you would like your gems applied: 1 Is your right side 6 is your left. While your preferred tooth selection will be considered, final placement may be modified at the technician’s discretion to ensure proper adhesion, safety, and the best overall result.*

1 (your right side)23456 (your left side)789101112
I, First Name* Last Name* authorize tooth gem technician to adhere a tooth gem to the following teeth selected in previous box. I acknowledge and understand that tooth gems do not adhere to crowns, caps, porcelain veneers or composite veneers for a long period of time. Tooth gems are best placed into a real tooth to ensure longevity. The placement of the tooth gems will be consulted by the technician to ensure longevity, recommend that the tooth gem be placed high on the tooth or in the centre, as the edges of the teeth sink into food when biting. If you choose to adhere the tooth gem on the lowest point of your tooth, technician can not ensure longevity and is not responsible for the tooth gem falling off.
I understand that tooth gems are temporary (up to 2 years) and are not intended to be permanent. I understand that the longevity of my tooth gem can be prolonged, depending on my compliance with after-care and lifestyle habits.*

I understand
I have voluntarily elected to undergo the tooth gem application procedure. I have read and understand the nature of this treatment.*

I understand
I understand and acknowledge that there are risks involved with the treatment I will be receiving. I have been informed of the possible benefits, risks, and complications, and I have had the opportunity to ask questions regarding these risks and other possible complications.*

I understand
I understand that it is more preferable to place a tooth gem in the centre or high on the tooth to prevent the risk of pre-mature tooth gem loss.**

I understand
I understand that my tooth gems may not be compatible with my removable appliances (orthodontic retainer, mouth guards, night guards, expanders and grills). I agree to bear the financial and time costs associated with having a new retainer made that would fit my tooth gems. I understand that by attempting to fit my appliances over my tooth gems, I can cause irreversible enamel damage and compromise my tooth gems.*

I understand
I understand that I should not try to remove my tooth gem myself and should have it removed professionally by a dental professional. This can be done at any time.*

I understand
I understand that when my tooth gem falls off naturally, there may still be residual dental adhesive on my tooth. I accept that it is my responsibility to seek a dental professional to remove the remaining adhesive on my tooth.*

I understand
Photo Release

I, the undersigned, grant permission to gemz by I and m lash and its representatives to photograph and/or record video of my teeth, smile, and/or services performed.I understand that these images and/or videos may be used for purposes including, but not limited to:Social media (Instagram, TikTok, etc.)Website and online marketingPromotional and educational materialsAdvertising and portfolio displayI acknowledge that:My identity will not be disclosed unless I provide explicit consent.No compensation will be provided for the use of these images or recordings.All media captured remains the property of Gems by I & m lash .I understand that I may opt out of photo/video use by notifying the service provider prior to my appointment, and that opting out will not affect my ability to receive services.By signing below, I confirm that I am at least 18 years of age and voluntarily consent to this release
Signature*
NO GUARANTEE OF RESULTS
Client understands that:

Cosmetic outcomes vary between individuals.

Retention duration cannot be guaranteed.

Absence of reaction cannot be guaranteed.
Signature*
RELEASE, INDEMNIFICATION & HOLD HARMLESS
Client voluntarily releases, waives, discharges, and agrees to indemnify and hold harmless the Technician and their business from any and all claims, liabilities, damages, costs, or expenses, including reasonable attorney’s fees, arising from this procedure or any future services.

This Agreement remains in effect for future tooth gem services unless revoked in writing.
Signature*
Tooth Gem General Information & Care:
Tooth gems are non-invasive and do not cause damage to the tooth or enamel. Tooth gems are semi-permanent and reversible. The tooth gems are 100% authentic, lead-free Swarovski Crystal. Once the tooth gem has been applied, there may be some remaining adhesive surrounding the tooth gem. This may wear off within 1-2 weeks from general brushing and eating. Tooth gems can last anywhere between 2-24 months. If you wish to remove your tooth gem before it naturally falls off, it can easily be removed at your next professional routine dental clean. Once your tooth gem does come away naturally, there may still be some residual adhesive remaining on the tooth. This too can easily be removed at your next professional routine dental clean. Please note that like any foreign object, there is a small chance that the chosen tooth may reject the tooth gem. If this occurs within 30 days of application, Isabel will offer a complimentary replacement.

If you undergo frequent teeth whitening sessions, or use at home teeth whitening products, the area underneath the tooth gem will not receive the whitening treatment. Please note: If you have porcelain or composite veneers, the longevity of your tooth gem is remarkably less than a real tooth. If you opt to adhere a tooth gem to your porcelain or composite veneers, you accept that Isabel are not responsible for the tooth gem falling off.

Agreement: I, First Name* understand that Isabel Maciel are not responsible for any damage made to my tooth/teeth during or after the tooth gem application. Removal of the tooth gem will be completed by a dentist or dental professional, and not attempted by myself.
After care

IMMEDIATE AFTERCARE ADVICE - MUST READ→ Avoid eating for the first hour. Drinking water is fine.→ Gentle toothbrushing using a soft-bristled, small headed non-powered toothbrush with a fluoridated toothpaste→ Avoid electric toothbrushes and pressured water flossers during the first 24 hours→ Avoid alcohol and acidic foods/drinks (e.g. soft drinks, energy drinks, fruit juice) especially during the first 24 hours→ Adopt a soft diet by avoiding hard, crunchy and sticky foods in the region of your tooth gem, especially during the first 24 hours (e.g. peanuts, chewing gum, toffee, bread crust, etc)→ Drink plenty of water to promote enamel hydrationMAINTENANCE ADVICE - MUST READ→ Maintain regular oral hygiene by flossing once daily and toothbrushing over your tooth gems to remove plaque and stains twice daily for two minutes. → If using an electric toothbrush, turn off the power when brushing across your tooth gem. → If using a water flosser, use gentle pressure only and avoid in areas adjacent to your tooth gems. Opt for regular floss in these areas.→ Avoid hard, crunchy and sticky foods in the region of your tooth gem. Eat with your back teeth or on the opposing side. → Use a straw when having acidic drinks. Alternatively, rinse with water after acidic foods and drinks. → Visit a dentist biannually, every 6 months to ensure your overall dental health is maintained
CLIENT ACKNOWLEDGMENT & SIGNATURE
By signing below, Client certifies:

They are at least 18 years of age (or have documented parental/guardian consent).

They have read this Agreement in its entirety.

They understand its contents.

They have had the opportunity to ask questions.

They voluntarily agree to proceed
MonthDayYear
Date
Signature of Client *
Should be Empty:

Tooth Gem Consent Form

Medical History

Authorization

Photo Release

NO GUARANTEE OF RESULTS

RELEASE, INDEMNIFICATION & HOLD HARMLESS

Tooth Gem General Information & Care:

After care

CLIENT ACKNOWLEDGMENT & SIGNATURE