Houston Tooth Gems Consent Form

Houston Tooth Gems Consent Form
Please read and check each box.

I acknowledge that these tooth gems are non-invasive and semi-permanent. If I decide I no longer want my tooth gems I will go to a dentist to have them properly removed. Due to Texas dental regulations, Houston Tooth Gems will not remove tooth gems.I understand that tooth gems placed on the curved edge of a tooth or on lower teeth take more pressure while chewing and may not last as long as tooth gems placed on the flat surface of an upper tooth.If my tooth gem falls off within 3 months of placement I will notify Houston Tooth Gems immediately to receive a free replacement. I understand that I may need a dentist to remove any remaining dental composite left on the tooth before putting a tooth them in that location. This guarantee does not apply to tooth gems provided by the client or tooth gems applied to veneers or crowns.I will let Houston Tooth gems know if I would like tooth gems placed on any surface other than natural enamel. There is a special preparation available for veneers/crowns/bridges but I understand that the bond will not be as strong as the bond with natural tooth enamel.I agree to avoid smoking or eating or drinking anything that might stain my teeth for at least 24 hours after my teeth whitening session. My teeth will be more susceptible to staining during this period.I acknowledge that Houston Tooth Gems and Battle Royale Tattoo are not responsible for any damage to my teeth (natural or man-made) during or after application of tooth gems or whitening sessions.I have read this whole document and I accept the terms indicated above.
Type of Service
Customer's Name*

First NameLast Name
Phone Number*
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
By signing below, you confirm that you have provided accurate and current information on this form. I affirm that I have made this consent and waiver voluntarily. In any case that I decide to withdraw or revoke my waiver, I may do so by submitting a written request signed by me to the salon company.
Customer's Signature*

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Date Signed*

MonthDayYear
Date
DL or Photo ID*
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