Tooth Gem Consent Form Terms and Conditions
1. I certify that this informed consent and waiver form was completed by me and that I understand all the questions, terms, and conditions, and all entries in it and information are true and complete to the best of my knowledge. I agree to observe and obey all posted written and oral rules and warnings, including on those
materials provided.
2. I agree to waive and release to the fullest extent permitted by applicable state law each of the Tooth Gem service provider and the management from all liability whatsoever, from any and all claims or causes of action that l, my estate, heirs, executors or assigns may have for personal injury or otherwise, including any direct or consequential damages, which may result or arise from the application of, or my accidental swallowing of tooth gems, whether caused by the negligence or fault of the Tooth Gem service provider.
3. l am 16 years old or over.
4. I understand that the application of tooth gems and products does not include any drilling into the tooth o breaking skin and may cause marks or discoloration of my teeth.
5. I understand that the application process of tooth gems may affect my tooth enamel, and I have been given the opportunity to talk about the risks associated with my Tooth Gem products with my tooth gem service provider.
6. I understand that the bonding agent used to apply my tooth gem may affect my teeth and that I have been given the opportunity to talk about the risks associated with the bonding agent with my Tooth Gem service provider.
7. I understand and agree that the tooth gem application procedure is semi-permanent and there is no guaranteed amount of time the products will remain on my tooth.
8. I understand that certain tooth gems may fall off for any or no reason after applying the gems to my teeth. So, I understand and agree that this salon is not responsible for replacing or substituting any products, including any gems, white gold, crystal, or gold charms, if my tooth gem falls off.
9. I understand that I should continue to see a dentist regularly to maintain proper oral health and hygiene for my teeth.
10. I have been advised that I should contact a dentist to remove all residue from the bonding agent from my tooth if my tooth gem falls off or if I wish to remove it.
11. I understand and will follow the aftercare instructions given to me by the Tooth Gen service provider to ensure the longevity of my tooth gem.
12. I have been advised to not bleach or perform blue light whitening procedures on my teeth because such procedures may affect the bonding agent used to apply my tooth gem and the tooth gem itself.
13. I agree to indemnify and defend this salon and its representatives, employees, contractors, and agents against all claims, causes of action, damages, judgments, costs, or expenses, including attorney fees and other litigation costs, which may in any way arise from my use of or presence upon the facilities of this salon.
14. I hereby authorize my Tooth Gem service provider and this salon permission to take photographs and use my likeness in a photograph or video for its promotional materials and publications, print and digital. I understand and agree that all rights to any photograph of me belong to this salon. If you do not authorize permission to take and use your photos, you must speak to our first impressions before the service
is rendered.
15. The invalidity or unenforceability of any provision of this Release of Liability shall not have any effect on any other provision of this Release of Liability or of any other applications of such provision, and such
unenforceable provision shall be deemed not to be a part of this Release of Liability.
16. The parties will attempt to resolve any dispute arising out of or relating to this Release of Liability through friendly negotiations. If the matter is not resolved, the parties agree to use mediation.
HAVE READ THIS DOCUMENT AND UNDERSTAND ITS CONTENTS. I FURTHER UNDERSTAND THAT BY SIGNING
WITH THIS RELEASE OF LIABILITY, I VOLUNTARILY SURRENDER CERTAIN RIGHTS. THIS SALON IS NOT RESPONSIBLE
FOR ANY DAMAGE CAUSED BY THE TOOTH GEM APPLICATION. IN CASE OF EMERGENCY CONTACT DR
I Agree and Give Consent with my Signature.
Terminos y Condiciones del Procedimiento de Tooth Gem.
1. Certifico que este formulario de renuncia y consentimiento informado fue completado por mí y que entiendo todas las preguntas, términos y condiciones, y todas las entradas en él y la información son verdaderas y completas a mi leal saber y entender. Acepto observar y obedecer todas las reglas y advertencias escritas y orales publicadas, incluso en los materiales proporcionados.
2. Acepto renunciar y liberar en la mayor medida permitida por la ley estatal aplicable a cada uno de los proveedores de servicios de Tooth Gem y la administración de toda responsabilidad, de cualquier reclamo o causa de acción que yo, mi patrimonio, herederos, albaceas o los cesionarios puedan tener por lesiones personales o de otro tipo, incluidos los daños directos o consecuentes, que puedan resultar o surgir de la aplicación o mi ingestión accidental de gemas dentales, ya sea por negligencia o culpa del proveedor de servicios de Tooth Gem.
3. Tengo 16 años o más.
4. Entiendo que la aplicación de gemas y productos dentales no incluye perforar el diente ni romper la piel y puede causar marcas o decoloración de mis dientes.
5. Entiendo que el proceso de aplicación de las gemas dentales puede afectar el esmalte de mis dientes y se me ha dado la oportunidad de hablar sobre los riesgos asociados con mis productos Tooth Gem con mi proveedor de servicios de gemas dentales.