Tooth Gems Release Form

Waiver: Acknowledgment and Consent: I, the undersigned, acknowledge and agree to the following: Informed Consent: I understand that the application of tooth gems involves placing a decorative gem on my tooth. The procedure requires the use of adhesives that are safe for dental use but may cause discomfort or allergic reactions in some cases. Potential Risks: I am aware that possible risks include, but are not limited to, irritation, sensitivity, or damage to the enamel or surrounding gum tissue. I understand that if I experience any adverse effects, I should seek professional dental advice. No Guarantee: I understand that the longevity of the tooth gems may vary and that there are no guarantees regarding the duration of adhesion or any potential impact on my oral health. Release of Liability: I hereby release, discharge, and hold harmless the service provider and their staff from any and all claims, liabilities, or damages arising out of or in connection with the tooth gems application. I understand that tooth gems are applied using dental adhesives and composites, and while I will take every precaution, there is a possibility that the gem or gems may fall off. In the event that a gem falls off, any adhesive or backing left on my tooth will require removal by a dentist, who may charge a fee for this service. I acknowledge that removals are not performed at this studio. I understand that within 30 days of application, I am entitled to a one time complimentary replacement for crystals that have fallen off; however, I may need to see a dentist for removal of any residual adhesive before reapplication can occur and replacement is subject to availability. Additionally, if a gold gem falls off within 30 days, I can replace it if I return the gold piece. If the gold is lost or swallowed, I understand that I will be responsible for the total cost of a new gold peice but reapplication fee for the gold piece within those 30 days is waived as a one time courtesy. Release of Liability: I hereby release, discharge, and hold harmless the service provider and their staff from any and all claims, liabilities, or damages arising out of or in connection with the tooth gem procedure. By signing below, I confirm that I have read and understood the above information and agree to the terms.