Clone of Tooth Gem Consent Form

Which Tooth Gem style? Pick 1 Only.

Acknowledgement of Risks & Agreement

I confirm I have been informed that tooth gem application is a cosmetic procedure using dental-grade adhesive, with no medical benefit. I understand the gem is not permanent and may last 1-12 months, but can fall off sooner due to my habits, aftercare, or placement.

I am aware of and accept the potential risks, including:

Premature detachment of the gem.
Plaque buildup, tooth decay, or gum irritation if cleaning is inadequate.
Minor enamel surface damage if removed incorrectly.
Rare allergic reactions or the remote possibility of inhaling/swallowing the gem if dislodged.

I agree to have the gem removed only by a qualified dental professional. I understand that while the procedure is performed with skill, no guarantee can be made against premature loss due to the nature of the product.

Aftercare Commitment

I agree to follow these aftercare instructions:

Avoid eating/drinking for 1 hour after application.
For 24 hours, avoid hard, sticky, or very hot items on the treated tooth.
Brush gently twice daily with a soft toothbrush and floss carefully.
Avoid biting hard objects and using my teeth as tools.
Continue my regular dental check-ups and inform my dentist of the gem.

Data Permission

I consent to LG Tooth Supply storing my details and this form securely for treatment and insurance records, in line with UK GDPR. I understand my data will be kept private and I can access it.

Final Consent

By signing below, I confirm I am over 18, have read this form, had all my questions answered, and voluntarily consent to this cosmetic procedure, understanding the risks and my aftercare responsibilities.

Your name

First NameLast Name

Date of Birth - Over 18s only

Date

E-mail

So that I can get back to you

Tooth Gems are Crystals attached to the tooth using bonding materials similar to braces, this does not cause damage to the tooth when aftercare is followed. We do not drill or use improper products for adhesion.

You do not have any medical conditions that affect your teeth or immune system (e.g., uncontrolled diabetes, osteoporosis)

If you have any allergies please let us know, we advise strongly against the application of Tooth Gems to anyone who may have an allergy/irritation to adhesives, chemicals such as HEMA & anyone who has had a reaction to nail products in the past.

Please do not proceed with treatment if you wear any style retainer or fitted device for your tooth.

You do not have any active cavities, gum disease, or require urgent dental treatment?

I confirm that I have not consumed alcohol or any substance that may impair my judgement or ability to give informed consent. I understand that the technician reserves the right to refuse treatment if they believe I am intoxicated or otherwise unable to consent.

Tooth Gems can fall off themselves at any point, we always advise that a Dentist is best to visit for full removal. We (Tooth Gem Techs) can not offer this service.

We do not apply gems onto pregnant or breastfeeding clients.

Tooth Gems can only be applied to Healthy Natural teeth, if you have any sensitivity, gum or dental issues or any alterations such as Composite Bonding, Veneers & even fillings on the selected tooth etc. We strongly advise against the application of Tooth Gems when these are present. We have the right to refuse treatment where we feel.

Do you consent to Temporary Tooth Gem application? (Can last from 1 month to 6+ Months) Please let us know if you would like your Gems to last a few hours to a few days! Please let you technician know too!

Risks & Liability - Potential risks include (but aren’t limited to): - Gem loss or adhesive residue -Temporary tooth sensitivity - Gum irritation if improperly placed - Do you agree?

I will not hold the technician liable for issues arising from: -Failure to disclose medical/dental conditions -Poor aftercare compliance -Pre-existing tooth/gum problems - Do you agree?

I confirm that I am over 18 years of age. I understand that by submitting this form I am declaring this truthfully, and that the technician reserves the right to refuse treatment if they have reasonable doubt about my age.

I confirm I have been informed that my technician is a trained tooth gem technician and is not a dentist or dental professional. This is a cosmetic procedure only and carries no medical benefit.

Please upload your ID/ Anything with Name/DOB Thank you :)