Cute Tooth Client Registration
Please fill out the following:
Name
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
How did you hear about us?
Google
Yelp
Instagram
Friend
Other
Have you ever had tooth gems before?
Yes
No
Dental History | Please check any of the following that applies to you:
Bleeding gums
Dental trauma
Veneers or crowns
Wear night guard or Invisalign
Untreated dental issues
Are or could be pregnant
HIV positive
Other
Any allergies? If yes, please list:
Are you ok with photos and videos?
Yes
No
Tooth Gem Consent, Release of Liability & Waiver of All Claims:
I am at least 16 years or older
I am voluntarily choosing to undergo the tooth gem application procedure after having the nature and purpose of the treatment fully explained to me.
I am NOT under the influence of alcohol or drugs, I am NOT pregnant or nursing
I understand that Cute Tooth and associated employees are not responsible for any damage done to the teeth or mouth during or after the tooth gem procedure.
I understand that tooth gems must be placed on a real, flat tooth and that false, crowned, or capped teeth are not a good candidates (bond will not adhere).
I understand that some dental adhesive may appear around the tooth gem and/or surrounding area and that the tooth gem application products may affect tooth enamel, cause marks or discoloration of teeth.
I understand that tooth gem removal must be performed by a dental professional and may cost additional money beyond what I paid for the gem.
I understand that tooth gems are not permanent and there is no guaranteed amount of time the products will remain on my tooth.
I understand that the longevity of my tooth gems relies heavily on the way I treat them and agree to follow the aftercare instructions given to me by Cute Tooth Gems.
I am aware of the possibility that my tooth gem can fall at any time and be swallowed.
I understand that Cute Tooth Gems will only provide replacement for crystal gems fallen off within 14 days of application. After the 14 days, I must pay to have my tooth gems reapplied if they fall off.
I understand that gold or opal charms can not be substituted and can only be reapplied with the original charm if fallen off within 14 days of application.
I elect to receive this procedure of my own free will and understand and accept all of the above information
I agree to indemnify and defend Cute Tooth and its representatives, employees, contractors, and agents, against all claims, causes of action, damages, judgments, costs or expenses, including attorney fees and other litigation costs, which may in any way arise from my use of, or presence upon the facilities of Cute Tooth Gems. The invalidity or unenforceability of any provision of this Release of Liability shall not have any effect on any other provision of this Release of Liability or of any other applications of such provision, and such unenforceable provision shall be deemed not to be a part of this Release of Liability. The parties will attempt to resolve any dispute arising out of or relating to this Release of Liability through friendly negotiations. If the matter is not resolved, the parties agree to using mediation.
I have read the Terms & Conditions and agree to its contents
Client Signature
Date
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Month
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Day
Year
Date
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