Tooth Gem Application Consent Form & Liability Waiver

Tooth Gem Application Consent Form & Liability Waiver

Please fill out the form to provide consent for the tooth gem application procedure.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Do you have any of the following;*

Tooth SensitivitiesGum DiseaseDental IssuesAllergiesOtherNone
Please explain..
(Tooth Sensitivity, Allergies, Other)
Acknowledgment and Waiver, Release of Liability

By completing and signing this form. I acknowledge that I have been given the full opportunity to ask any and all questions which I might have about obtaining a tooth gem from Bling by Cherry, and that all of my questions have been answered to my full and total satisfaction. I specifically acknowledge that I have been advised of the facts and matters set forth, and I agree as follows:
Client Signature*

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Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
All sales are final and no refunds. If your tooth gem falls off within the first 30 days, I will reapply one time at no cost. You must contact me to set up an appointment at my studio location. If you need to contact me you can email me Info@inkdbycherry.com or call me 469.228.8848
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