Tooth Gem Intake Form

Tooth Gem Intake Form
General Information
Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Preferred Pronouns
Phone
Format: (000) 000-0000.
Email
example@example.com
Emergency Contact Name
Phone
Format: (000) 000-0000.
How did you hear about me?
Are you currently taking any medications?
If yes, please explain
Do you have any allergies?
If yes, please explain
When was your last dental cleaning?
Have you had tooth gems before?
Do your gums bleed when you brush?
I care about your oral health so please be aware:

Bleeding, Swollen gums are often signs of gingivitis, the early stage of gum disease, and can be caused by plaque and bacteria buildup on teeth. This inflammation can lead to red, tender, and easily bleeding gums, particularly when brushing or flossing. While bleeding gums can sometimes be a minor issue, persistent bleeding or swelling warrants a visit to the dentist for proper diagnosis and treatment.

Ask me about my 20% off discount if you have been to the dentist within 60 days of your appointment!
I will not adhere gems to teeth with excessive plaque buildup, signs of decay, or gum disease in order to keep you safe from further damage.
Do you have sensitive teeth?
If so, explain your sensitivity:
Do you wear a retainer?
Are any of your teeth you want gems on crowns, veneers or implants? (Gems can only be adhered to a real, natural tooth enamel)
Is there anything else I should know before your appointment?
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.
Name Printed
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Tooth Gem Informed Consent Form & Liability Waiver
I have voluntarily elected to undergo the tooth gem application procedure after the nature and purpose of this treatment has been explained to me.
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
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.
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.
I understand that tooth gems can last between a few months to a year and are not meant to be permanent
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.
I understand that I should not try to remove my tooth gem myself and should have it professionally removed by a dental professional.
Attempting to remove your gem at home may result in damage to your enamel, pain, discomfort, or injury!
Please do not attempt to remove at home. If you choose to do so, I am not responsible for the result.
I understand that if I want to remove the gem I will have to go to the dentist.
I understand that when my tooth gem falls off naturally, there may still be residual bond left on the tooth
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.
I understand that there are no refunds offered for this service.
UPLOAD DESIGN INSPO HERE :3

Please include any pictures to help me get an idea of what you might want to get
Cancelof
By signing below, 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.
Printed Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty:

Tooth Gem Intake Form

General Information

Tooth Gem Informed Consent Form & Liability Waiver

Attempting to remove your gem at home may result in damage to your enamel, pain, discomfort, or injury! Please do not attempt to remove at home. If you choose to do so, I am not responsible for the result.

Attempting to remove your gem at home may result in damage to your enamel, pain, discomfort, or injury!
Please do not attempt to remove at home. If you choose to do so, I am not responsible for the result.