Tooth Gem Client Consent Form

Client Information

First name

Last name

Date of birth

Day

Month

Year

Todays Date

Date of Treatment

Multi-line address

Country/Region

Address

City

Zip / Postal code

Contact Number

Email

Tooth gems are a cosmetic dental accessory bonded to the surface of a natural tooth using dental-grade adhesive. No drilling or permanent alteration to the tooth is involved when applied correctly and professionally.

PLEASE CONFIRM BY CHECKING THE FOLLOWING:

I confirm that I am 18 years of age or older.

I confirm that I am not pregnant.

I confirm I do not have veneers, crowns, bridges, braces, or dental implants on the area being treated.

I confirm that I do not suffer from gum disease, severe tooth sensitivity, enamel erosion or untreated cavities.

I understand that tooth gems are cosmetic only and not a dental treatment.

I understand that results and longevity may vary depending on oral hygiene, lifestyle, and natural enamel.

I understand that the tooth gem may detach over time and this is not guaranteed.

I understand that removal, if required, should be carried out by a dental professional to avoid enamel damage.

I understand that good oral hygiene is essential after treatment.

Any known allergies:

Any additional information regarding medical conditions or allergies we should know about:

Liability and Consent

By signing this form, I acknowledge that:

Tooth gem application is a non-medical cosmetic service.
The practitioner is not a dentist.
No guarantee has been made regarding longevity or appearance.
I accept full responsibility for any aftercare and future dental consideration.

I give my full informed consent to proceed with tooth gem application.

I voluntarily consent to photographs and video recordings being taken of me and authorise Extremes Salon to use this content across its social media platforms and other marketing materials.

Please give us some information about the Tooth Gem design you are hoping to achieve (a full consultation will take place on the day of your treatment, you can upload images below as reference photos):

File upload

Upload up to 5 inspiration pictures.

Signature

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