Tooth Gem Consent Form

Client Information and Consent

First Namerequired
Last Namerequired
Date of Birthrequired
Emailrequired
Phone (Digits Only)required

CONSENT

requireddb save
I am voluntarily undergoing

1. I am voluntarily undergoing the tooth gem application, fully understanding its nature and purpose.


requireddb save
I am aware

2. I am aware that if I have swollen or bloody gums, visible decay, visible trauma to my teeth or significant build-up, I will be refused service.


requireddb save
I confirm

3. I confirm that I am not under the influence of alcohol or drugs and desire to undergo the procedure.


requireddb save
I acknowledge

4. I acknowledge the potential risks to my dental health from improper aftercare and understand the importance of regular oral hygiene and dental check-ups to maintain tooth gems.


requireddb save
I understand

5. I understand that tooth gems are temporary, lasting between 3 months to 2+ years.


requireddb save
I am aware

6. I am aware that teeth whitening does not affect the area under the tooth gem.


requireddb save
I am am willingly electing

7. I am willingly electing the procedure, accepting responsibility for any damage, and understanding that aftercare is the responsibility of a dental professional.


requireddb save
I recognize

8. I understand that a dental professional must remove the gem and any residue, and that removal costs depend on the clinic and my insurance.


requireddb save
I acknowledge

9. I acknowledge that false, crowned, or capped teeth are not suitable for tooth gems due to adhesive issue.


Client Info

Are you HIV positive?

Yes
No
I’m not sure

How would you like your appointment to go?

I’m a social person and I love to chat.
I would prefer my appointment to be strictly gem related.
Indifferent.

Are you ok with photos/videos for use on social media (non-identifying)?

Ok with photos and videos.
Ok with photos.
Ok with videos.
None of the above.

Date: 26.03.2024

Time: 6:38 PM

Signature of Clientrequired
Tap to Sign

Parent/Legal Guardian (if Client is under 16)

Parent/Legal Guardian Nametextoptionalnot save
Relationshiptextoptionalnot save
Parent/Legal Guardian Signatureoptionalnot save
Tap to Sign

Date: 26.03.2024

Time: 6:38 PM


I would like to get a copy of this document. I confirm my email address is spelled correctly.
I agree to Waiver Master Terms & Conditions and Privacy Policy available at waivermaster.com/terms.html and waivermaster.com/privacy.html.

By clicking/tapping/touching/selecting or otherwise interacting with the "Submit" button below, you are consenting to signing this Document electronically. You agree your electronic signature ("E-Signature") is the legal equivalent of your manual signature on this Document. You consent to be legally bound by this Document's agreement(s), acknowledgement(s), policy(ies), disclosure(s), consent term(s) and condition(s). You consent to be legally bound by Waiver Master's policies, terms and conditions available at waivermaster.com/terms.html and waivermaster.com/privacy.html . You agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature. You may request a paper version of an electronic record by writing to us. We reserve the right to charge a reasonable fee for the production and mailing of a paper version of the record. Your current valid email is required for all communications.




Submission Sequence: 2024-04-08T15:23:15.198Z3
DUUID Sequence: UPSQ8A85HNG_65180d03-65a0-4634-803a-d38c8f0d1480
IP(s): 70.64.25.250, 18.68.41.53
CFID: GAfbYGOm2DvCufVU-JSErnBEhveL1jmyy13_8-alyPG-DrxghPP-3Q==
TRACEID: Root=1-66140be3-4fa8328765379dc71369ca91
UA: Mozilla/5.0 (Linux; Android 10; K) AppleWebKit/537.36 (KHTML, like Gecko) SamsungBrowser/24.0 Chrome/117.0.0.0 Mobile Safari/537.36