Tooth Gem Consent Form

Let us do this part

Today's Date:

Tue Apr 29 2025 03:38

Please fill in the Tooth Treasure Release Form to the best of your ability. If you have any questions please ask a member of staff.

Please read and answer

MEDICAL*

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

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

Details:

Have you consumed alcohol or drugs in the last 24 hours?

AFTERCARE/REMOVAL*

I agree to follow the aftercare routine given to me during my appointment.
I have answered the above information truthfully and to the best of my ability
I understand that removing my tooth gems will need to be performed by a Dentist and the tooth gem technician is unable to do this

LIABILITY RELEASE*

I acknowledge that I have been given adequate opportunity to read and understand this document, that it was not presented to me at the last minute

I understand it is my right to withdraw from the Tooth Gem procedure at any time, however I will not be entitled to a refund once the Technician has set up, as there are set up costs and Technician time incurred.

GDPR*

I understand that my information (data) given on this form will be stored as an electronic copy and will not be stored physically. The information is stored by The Owl and the Pussycat Piercing LTD only and will not be used for marketing purposes or passed on to third parties. By signing our consent form, our clients ackowledge that we are compliant with GDPR regulation and that their information is stored correctly and not passed on

PHOTOGRAPHY*

I release all rights to any photographs taken of me and my Tooth Treasure and give consent in advance for their reproduction in print or electronic form

16+*

I confirm that I am over the age of 16 and will provide my government issued photo identification to a member of staff when asked to prove my age & date of birth.

LIABILITY RELEASE*

I confirm I am of sound mind and are to follow the aftercare provided and the longevity of the tooth gem will depend on how well I look after them and follow the aftercare.

I understand that by going ahead with the 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: