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Tooth Gems

Let us do this part

Today's Date:

Fri Dec 27 2024 11:32

Practitioner:*

Please read and answer

Allergies:*

Please list any allergies you have:

Details:

Medical:*

Do you have, or have you recently been affected by any of the following?
Abscess/Ulcer, Ongoing Dental Problems, False Tooth/Veneers, Pregnant/Brest Feeding, Invisalign/Retainer, Halitosis, Oral Herpes, Recent Dental Surgery, Sensitive Teeth.

Details:

Illness:*

Within the last 48 hours, Have you experienced any vomiting, diarrhoea or any form of virus or infection?

Photography:

I release all rights to any photographs taken of me and the Tooth Gem and give consent in advance to their reproduction in print or electronic form.

I Confirm that i am of sound mind and agree to follow the aftercare provided. I understand that my tooth gem can last anywhere from a month to one year depending on how well i look after them and to achieve longevity i must follow the aftercare.
I understand that by going ahead with treatment all information provided is correct and i am going ahead at my own discretion.

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.

Client Information

I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.

Legal Name:*

Pronoun:

Chosen name:

Address:*

Postcode:*

Date of birth:*

You must be 16 or older

Phone #:*

Email:*

Signature:*

Sign above or type signature:

Photo ID

Please take photo(s) of your government issued photo IDs and related paperwork.