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Tooth Gems
Let us do this part
Today's Date:
Thu Oct 8 2026 02:48
Tooth Gems applied by Luxurious Enamel
Please read and answer
Y
N
Do you have any allergies? If YES, please explain.

Details: 
Y
N
I agree that the tooth I have chosen for tooth jewel application has no cracks, chips, or holes. It is not damaged or requires dental treatment.

It is also NOT a denture, crown, cap or veneer as this dental bond will not adhere to any of these.

I understand that if I wear clear retainers or Invisalign aligners they will not fit over tooth gems.
Y
N
I understand that the tooth gem is semi-permanent & can last anywhere from 1 month to 2 years and beyond depending on how I take care of it & what i eat/drink.

If tooth gem (crystal) has prematurely fallen within the 45 day grace period and are looking to get the tooth gem replaced. The replacement will be the exact same service as the original (exact same tooth, crystal and size.)
Y
N
1. Do not eat/drink or touch the jewel for at least 30 minutes after application

2. Do not remove the crystal/gem with any sharp objects. If you want the crystal/gem removed before it falls off naturally, go to your dentist. If the gem falls off, residual bond may be left on the tooth. Go to your dentist for proper removal.

3. If using an electric toothbrush, turn the brush off when brushing the gem as it could loosen the gem.

4. Do not put any tooth whitening gel directly on the gem when getting your teeth whitened.

5. Eating sticky and tacky foods could make your gem fall off faster

6. I agree to maintain normal dental hygiene like brushing/flossing and seeing the dentist ever 6 months for check ups.
Y
N
I authorize Luxurious Enamel to capture and use your pictures for promotional purposes
Y
N
By signing below, I agree that I have read and fully understand this agreement & all information detailed above. I understand the procedure & accept the risks. I agree & will assume the risk and full responsibility for any injuries, losses, side effects, or damages that might occur to me while I’m performing the procedure. I do not hold the technician responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed by myself today.
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 or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this agreement.
Name:*
Date of birth:*
 
If you are under 16 your parent/guardian will be required
Age: 
Phone #:*
Email:*
Social Handle:
If you don't mind us tagging you in photos online
Signature:*