Tooth Gems Questionnaires & Consent Form

Tooth Gems Questionnaires & Consent Form
Are you filling this form for yourself or for a minor?*

MyselfFor a minor
Are you 18 years old or older?*

YesNo
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Is this your first time getting tooth gems?*

YesNo
Are you allergic to any medication or adhesive?*
Do you have veneers, crowns, or dentures on your teeth?*

YesNo
Do you have to wear teeth retainers (at night)?*

YesNo
PROOF OF IDENTIFICATION
Type of document
Picture of Your Identification*

Cancelof
PHOTOS AND VIDEOS RELEASE
I have been informed that Tonna Sky Beauty may record videos and take pictures of me during my appointment for social media and marketing purposes.

I understand that the videos and pictures may be used on various marketing platforms, including but not limited to social media websites, promotional materials, and advertisements.

I acknowledge that my participation in the recording of videos and taking of pictures is voluntary and that I will not receive any financial compensation for the use of these materials.
I choose the following:*

I agree to the recording of videos and taking of pictures as described aboveI deny consent for the recording of videos and taking of pictures as described above
TOOTH GEM CONSENT AND RELEASE FORM
I, the undersigned, acknowledge that by signing this release, I have been given a full and fair opportunity to ask any and all questions I might have regarding the application of tooth gems from Tonna Sky Beauty (hereinafter referred to as "Technician"). I confirm that all my questions have been answered to my complete satisfaction. I specifically acknowledge that I have been informed of the matters set forth below and agree to the following terms. (If any of the following are not checked, I understand that I may not be able to proceed with the tooth gem application session, and I will confirm with the Technician beforehand.)*

1. Understanding of Procedure: I understand that the application of tooth gems involves no drilling into my teeth and does not break the skin. However, I acknowledge that the procedure may result in marks or discoloration of my teeth.2. Bonding Agent Effects: I understand that the bonding agent used to adhere the tooth gem may have an effect on my teeth. The composite resin used in bonding is not as strong as natural tooth enamel, making it susceptible to chipping or breaking if exposed to excessive force or hard foods.3. Staining potential: Bonding material can absorb stains from food and drinks like coffee or red wine, leading to discoloration over time.4. Semi-Permanent Procedure: I understand and agree that the tooth gem application is semi-permanent, and there is no guarantee of how long the tooth gems will remain on my teeth.5. Gem Replacement: I understand that tooth gems may fall off for reasons beyond my control. Tonna Sky Beauty and its Technicians offer one free replacement of the tooth gem within 1 month of the initial application appointment. The replacement will be limited to Preciosa crystals and opals. For gold or diamond gems, I understand that the replacement cost will be based on the value of the piece.6. Oral Health Maintenance: I understand that it is my responsibility to maintain regular dental check-ups to ensure proper oral health and hygiene.7. Removal of Tooth Gem: I understand that if my tooth gem falls off or I wish to have it removed, I should consult a dentist to properly remove the bonding agent residues from my tooth.8. Disclosure of Allergies: I have informed the Technician of any allergies I may have to latex gloves, soaps, or medications. I understand that it is not the responsibility of the Technician to determine whether I will have an allergic reaction.9. Aftercare Instructions: I agree to follow the aftercare instructions provided by the Technician in order to maximize the longevity of my tooth gem.10. Avoidance of Certain Dental Procedures: I have been advised not to bleach or undergo blue light whitening procedures on my teeth, as these treatments may affect both the bonding agent and the tooth gem itself.11. Waiver of Liability: To the fullest extent permitted by law, I hereby waive and release Tonna Sky Beauty, its agents, employees, and contractors from any and all liability, including but not limited to personal injury, damages, or claims that may arise, whether caused by negligence or otherwise, as a result of the application of my tooth gem.12. No Refund Policy: I acknowledge and agree that Tonna Sky Beauty has a strict no-refund policy regarding tooth gems and retail sales and that no refunds will be issued under any circumstances.
By signing below, I confirm that I have read, understood, and agree to the terms outlined in this consent form.
Signature*
Print Name*

First NameLast Name
Date*

MonthDayYear
Date
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Tooth Gems Questionnaires & Consent Form

PROOF OF IDENTIFICATION

PHOTOS AND VIDEOS RELEASE

TOOTH GEM CONSENT AND RELEASE FORM