Poly Ink Tooth Gems Consent From✨

  • Poly Ink Tooth Gems✨

    Consent form
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  • Format: (000) 000-0000.
  • Have you had tooth gems before?
  • Do you have any medical conditions or allergies?
  • Are you currently taking any medications?
  • Do you have sensitive teeth?
  • I have elected, by my own decision, to have this Tooth Gem application
  • I understand any and all aftercare associated with the application of a tooth gem and intend to follow the aftercare procedures provided to me.
  • I understand and acknowledge any risks or complications associated with the procedure as they have been explained to me.
  • I have been given the opportunity to ask questions regarding anything associated with the procedure.
  • l understand that a tooth gem must be adhered to my real and natural tooth and that a false tooth. crown, or cap is not advised as a good candidate for tooth gem application.
  • I understand that immediately after the application there will be dental adhesive around the gem and that this adhesive will wear off with time given that I follow proper aftercare of brushing and eating.
  • I understand that tooth gem applications are not permanent and may last between 2 months and a year, sometimes longer, but there is no guarantee of the amount of time it will last.
  • I understand that I should not remove a tooth gem myselfand it should be removed by a dental professional.
  • I understand that after the tooth gem falls off there may be residual adhesive remaining on the tooth that should be removed by a dental professional.
  • I understand that any whitening procedures done while my tooth gem is on will not affect the area under my tooth gem and thus a color difference may be visible upon the removal or falling off of my tooth gem.
  • I understand that the application process may affect my tooth enamel.
  • I understand that tooth gems may fall off for no apparent reason and that my technician is not responsible for replacing or substituting the gems.
  • l attest that I have given an accurate account of my medical history, including any allergies or prescription drugs that I am currently taking or intend to take.

  • With my signature below, I attest that I have read and fully understand this consent form and all details from above. I have provided accurate information concerning my medical history including medications that I take or any medical procedures I intend to undergo or prescriptions I intend to take. By signing below, I assume all and full responsibilities for any risks or injuries, losses. side eflects damages, that may occur as part of the procedure. I will not hold my tooth gem technician or Poly Ink Customs responsible for any conditions present at the time of treatment but not disclosed that may affect the treatment. I agree to Poly Ink Customs using any pictures and/or videos taken for social media, content, promotions, marketing and advertisement purposes. I understand that there are no refunds, and all deposits/payments are final.

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