False Tooth Gem Consent Form

TOOTH JEWELLERY CONSULTATION FORM
Before we start, you need to fill out a short medical form in order to make your treatment as effective and safe as possible. Please note that all information is strictly confidential.
Name

First NameLast Name
Prefered Name
Prefered Pronouns
Age
Date of birth

DayMonthYear
Date
Contact Number
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Allergies
DO YOU HAVE, OR HAVE YOU RECENTLY BEEN AFFECTED BY ANY OF THE FOLLOWING?

Please let us know as for your safety, we may not be able to go ahead with your service today
WITHIN THE LAST 48 HOURS, HAVE YOU EXPERIENCED ANY VOMITING, DIARRHOEA OR ANY FORM OF VIRUS OR INFECTION? YES / NO
I understand that false teeth applications are unpredictable and longevity cannot ever be guaranteed, even with correct technique and aftercare. I accept that veneers, crowns and dentures may not hold as well as natural enamel and early lifting does not qualify for free fixes or refunds.
I understand that the application will temporarily create a matte finish on the section of porcelain where the gem is applied. I also understand that dentists and hygienists can professionally polish the veneer to restore shine. I understand that if I no longer want my gem or wish for it to be changed, that I will need a scale and polish to remove at my expense as a client
I acknowledges that this is a cosmetic service only and does not replace dental treatment or advice. I confirm that I do not have untreated dental issues such as infections, loose crowns/veneers, sensitivity, gum swelling or recent dental work. I understand all risks related to bonding on manufactured teeth and accept full responsibility for choosing the service.
I confirm that I am of sound mind and agree to follow the aftercare provided. I understand that my tooth gem can last anywhere from one month to one year depending on how well I look after them and to achieve longevity I must follow the aftercare.
I allow my tooth gem to be photographed and the process recorded and for those images to be used on my tooth gem technician's website and social media accounts.
I acknowledge Blank Collective & Crystal Canine do not offer refunds.
I indemnify and hold harmless Blank Collective LTD & Crystal Canine LTD against any claims, expenses , damages and liability.
I understand that by going ahead with treatment all information provided is correct and I am going ahead at my own discretion.
Client Signature
How did you find out about us

Other
Date

DayMonthYear
Date
Please upload a copy of your ID (passport or driving license)

Cancelof
Notes, please leave this section clear and it'll be used if necessary by your technician.
Should be Empty:

TOOTH JEWELLERY CONSULTATION FORM

DO YOU HAVE, OR HAVE YOU RECENTLY BEEN AFFECTED BY ANY OF THE FOLLOWING?