Statements Of Consent
I have truthfully represented to Amonara Creations that I am over 18 years of age or have my parent/ guardians consent.
I voluntarily choose to undergo this dental rhinestone/ gold jewelry placement procedure, the nature and purpose of which have been clearly presented to me.
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.
I am aware that there are no guaranteed results and that these depend on the acidity of saliva, which is specific to each individual.
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.
I understand that my tooth artist's suggestions are not medical advice.
I understand I am responsible for looking after my tooth jewelry by following the aftercare instruction's provided.
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.
I understand sterilized jewelry and equipment and/ or single use disposables will be used for my tooth gem procedure.
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.
I am fully aware of and take full responsibility for the tooth gem process and aftercare instructions provided by my tooth gem artist.
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.
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.
By signing this form, I agree to the statements of consent & that all information is truthful and accurate.
