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Consent Form (Tooth Gem)
Studio: [Studio Name]
Technician: [Technician Name]
Client: [Client Name]
Appointment: [Appointment Date] at [Appointment Time]
Client Information
•Phone: [Client Phone]
•Email: [Client Email]
•Date of Birth: [Client Dob]
Placement Details
•Tooth / Location: [Tooth Location]
•Gem Style / Shape: [Gem Style]
•Gem Material: [Gem Material]
•Adhesive Used: [Adhesive Type]
Please read and initial each item
I confirm I meet the minimum age requirement for this service.
I confirm that my decision to get a tooth gem is entirely my own.
I confirm that I am not currently experiencing tooth pain, sensitivity, a cracked tooth, active decay, gum disease, or dental work in progress on the tooth being treated. I understand that tooth gem application is not recommended on teeth with these conditions.
I understand that if I am unsure about my dental health, I should consult a dentist before proceeding with this service.
I understand that a dental-grade adhesive is used to bond the gem to the enamel surface. The process involves light etching of the tooth enamel, which is a standard bonding technique.
I understand that tooth gems typically last [Duration Estimate] with proper care, but individual wear time can vary based on placement, bite, oral hygiene habits, and lifestyle.
I understand that duration cannot be guaranteed, and that the gem may come off sooner than expected without any fault of the technician.
I understand that if the gem comes off on its own, I should not attempt to reattach it with non-dental adhesives. I should contact the studio or a dentist if concerned.
I understand that [Studio Name] is not a dental office, and this service is a cosmetic procedure. This is not dental treatment and does not replace regular dental care.
I understand potential risks including: discomfort during application, minor enamel etching at the bond site, difficulty cleaning around the gem, and the possibility of swallowing the gem if it detaches.
I agree to follow the aftercare instructions provided.
I had the opportunity to ask questions before the procedure.
** I consent to before/after photos for the technician's portfolio and marketing use. I understand I may decline this without affecting my service.
Health and Safety Screening
•Known allergies (latex, acrylics, dental adhesives/composites)?
Yes — describe: [Allergy Details]
No
•Active dental treatment in progress (orthodontics, ongoing dental work)?
Yes — describe: [Dental Treatment Details]
No
•Teeth grinding or jaw clenching?
Yes
No
Grinding significantly shortens gem lifespan and may increase wear on the tooth.
•Veneers, crowns, or bonding on the treatment tooth?
Yes — describe: [Dental Work Details]
No
Other notes::
I certify that I have answered the above questions truthfully.
Client Signature: ______ Date: ______
Technician/Staff Signature: ______ Date: ______