Tooth Gem Consent Form
Review and confirm your consent for tooth gem placement before the appointment.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Do you have any allergies (especially to adhesives, metals, or dental materials)?
*
Yes
No
Please list any allergies or relevant medical conditions.
When was your last Dental Cleaning?
Have you had any recent dental work or oral surgery (within the last 6 months)?
*
Yes
No
Do you have any false, crowned or capped teeth or veneers?
*
Yes
No
Signature
*
Date of Consent
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: