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TOOTH GEM INFORMED CONSENT AND RELEASE OF LIABILITY WAIVER

1. I certify that this informed consent and waiver form was completed by me or a legal guardian and understand there are risks involved with the treatment I will be receiving. I agree to observe and obey all written rules and warnings, including on those materials received by Emily Smith.

2. I am 18 years or older or have my legal guardian present. I am not under the influence of drugs or alcohol.

3. I understand that the application of tooth gems and products does not include any drilling into the tooth and may cause marks or discoloration of my teeth. I understand that the tooth gem application procedure is semi permanent and there is no guaranteed amount of time the product will remain on my teeth.

4. I understand that some tooth gems may fall off for any or no reason after applying the product to my teeth. I understand and agree that the studio is not responsible for replacing or substituting any products if my tooth gem falls off.

5. I understand I should still see a dental professional regularly to maintain proper oral health and hygiene for my teeth.

6. I agree to not move any gems or products from my teeth myself. I understand and will follow aftercare instructions given to me to ensure longevity of my tooth gems.

7. I have notified a staff member of any allergies I have.

8. I understand a tooth gem must be placed on a real tooth and not a false, corned, or capped tooth. 

9. I understand that the tooth gem will need to be removed by a dental professional, removal will not be offered as a part of the service.


By signing below I agree to all terms and conditions stated above and agree to any and all risks and alterations. I agree to release and forever discharge and hold harmless the artist and all employees from any and all claims, damages or legal actions arise from or connected in any way with my tooth gem, procedure and conducts used in my tooth gem.

Please select who will be participating...
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First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
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Minor ID and Type

Minor ID type

Minor ID number
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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