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Tooth Gem Consent Form

Health Declaration

Please read & fill out the entire form.

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This is an agreement between the piercer and the client, indicating that full communication has taken place to ensure a legal, safe, and successful body piercing.

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Statements Of Consent

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I have truthfully represented to Amonara Creations that I am over 18 years of age or have my parent/ guardians consent.​​​​

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I voluntarily choose to undergo this dental rhinestone/ gold jewelry placement procedure, the nature and purpose of which have been clearly presented to me.

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I acknowledge that I have been informed of the risks associated with the procedure I will undergo.  Although it is impractical to list all potential risks and complications, I have been informed of the possible benefits, dangers, and possible complications.  I have also had the opportunity to ask any questions I may have about the possible risks and complications, and I have been informed of the products that will be used. 

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I am aware that there are no guaranteed results and that these depend on the acidity of saliva, which is specific to each individual.

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I understand my tooth artist cannot be held responsible if my body reacts negatively to the metal of the jewelry or bonding products used during the procedure.

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I understand that my tooth artist's suggestions are not medical advice.

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I understand I am responsible for looking after my tooth jewelry by following the aftercare instruction's provided.

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I acknowledge that if I decide to remove my jewelry, I will see my dentist or tooth gem artist for removal and will not attempt to remove the jewelry on my own. 

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I understand sterilized jewelry and equipment and/ or single use disposables will be used for my tooth gem procedure.

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This is to certify that I, the above named and undersigned, do give my permission to my tooth gem artist to move forward with my procedure at Amonara Creations.

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I am fully aware of and take full responsibility for the tooth gem process and aftercare instructions provided by my tooth gem artist. 

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I have also provided, to the best of my knowledge, an accurate medical history, including any known allergies and prescribed medications or products that I am currently taking or applying to prevent any risk of complications. 

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I have read and understood the agreement and all the information previously provided.  I acknowledge the stages of the procedure and accept the associated risks. I agree to assume full responsibility for any injuries, losses, side effects or damages that may occur during or as a result of the procedure.  I will not hold the dental jewelry professional, whose signature is indicated below, responsible for any pre-existing condition not disclosed at the time of the procedure that may be influenced by the care provided on this day. 

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By signing this form, I agree to the statements of consent & that all information is truthful and accurate.

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Please upload a copy of your ID.
Other Form of ID (If Applicable)
Parent/ Guardian's ID

Thanks for submitting!

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