You will be required to sign a Tooth Gem Consent form at your appointment.

INFORMED CONSENT TO TOOTH GEMS

I have been given this information in order to make an informed decision about undergoing a tooth gem procedure. I am able to take as much time as I need to come to a decision on whether or not to sign this informed consent form. I am free to ask any questions about the procedure before I consent to it.  

I understand that I am not being treated by a dentist, my technician has no dental qualifications, and my teeth are not being examined for health, cavities, etc. I am aware that I should be examined by a dentist prior to the procedure. I have been advised by my dentist that I currently have healthy teeth and gums. I understand that tooth gems can not be placed on artificial teeth.

I understand tooth gems with Crystal Whitening may last anywhere from 2 months to 36 months depending on personal care and lifestyle.

I understand that tooth gems can only be removed by a dentist or hygienist. Crystal Whitening is not responsible for the removal of tooth gems.

I have read and understand the pre and post-treatment instructions. I agree to follow these instructions carefully. I understand that compliance with recommended pre and post-procedure guidelines is crucial. The nature and purpose of the treatment have been explained to me. I have read and understand this agreement. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. 

I release Crystal Whitening, staff, and all specific technicians from liability associated with the procedure. I certify that I am a competent adult of at least 18 years of age and/or I am a competent adult parent or legal guardian of the minor listed below. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors, and assigns. 

By signing this informed consent, I am stating that I have read the information provided in this informed consent (or it has been read to me), the procedure has been explained to me, I understand the procedure, with its possible risks, complications, and benefits, all my questions have been answered to my satisfaction, and I consent to undergo this tooth gem procedure. 

I understand I must be 18 years or older, or have a parent/legal guardian sign for me. 

We ask that you please reschedule, or cancel, at least 24 hours before the beginning of your appointment or you may be charged a cancellation fee of $25.00.