• Client Intake & Consent Form

    Client Intake & Consent Form

    Tooth Gems
  • Date
     - -
  • Format: (000) 000-0000.

  • Dental Information

  • Do you have any allergies or sensitivities with dental materials?*
  • Are you currently taking any medications?*
  • Do you have any false, crowned or capped teeth or veneers?*
  • Do you have sensitive teeth?*

  • By signing below, I agree to the following: I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any conditions that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward my technician for any injury or damages occurs due to any misrepresentation of my health.

  • CONSENT FORM

    Please select "Yes" to initial.

  • By signing below, I verify that I have read and understood the above statements and agree to them. I understand the procedure and accept the risks. I do not hold the technician, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today.

  • Date*
     - -
  • Should be Empty: