Gem&Grin consent form

Gem&Grin Client Consent Form
Please complete this form before your tooth gem appointment. The information provided will be kept securely and used to ensure your treatment is carried out safely

Please read and answer

Do you require silent appointment?*

Details:

I agree with posting my full face picture on Gem&Grin social medias*

I would appreciate it if you agree with me posting your picture on my Instagram, although it is completely fine for you to say no or crop the picture so that only the tooth gem applied will be visible.

Details:

Do you have Flu like symptoms?*

IF YOU HAVE:
- a fever
- flu-like symptoms
- shortness of breath
-vomiting
-diarrhoea

YOU NEED TO NOTIFY A STAFF MEMBER IMMEDIATELY.

Details:

Bloodbourne Pathogens*

Do you have any bloodbourne pathogens, transmittable diseases or recent illnesses? (It' okay if you do, we just want to know for our and other's safety).

Details:

Questions*

Artist have given me the full opportunity to ask any and all questions about the tooth gem procedure and the they have been answered to my total satisfaction.

Aftercare*

I confirm that I have been given aftercare instructions and I understand them and will follow them. I acknowledge that it is possible that the tooth gem can come off particularly if I don’t follow the instructions.

This Document*

I acknowledge that I have been given adequate opportunity to read and understand this document, that it was not presented to me at the last minute, and I understand that I am signing a legal contract.

Photography*

I release all rights to any photographs taken of me and the tooth gems and give consent in advance to their reproduction in print or electronic form.

Declaration*

I acknowledge that all information I have provided is accurate and by proceeding with the treatment I do so at my own discretion.

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.

Name:*

Address:*

Postcode:

Date of birth:*

You must be 16 or older

Age:

Phone #:*

Email:*

Signature:*

Sign or type signature:

Parent/Legal Guardian

I, as custodial parent or legal guardian of the above minor under -16 years of age, hereby consent to the terms and conditions set forth in this release form and I attest that all documentation I have provided is true and accurate.

Please add a photo ID by clicking "Add picture"

Legal Name:*

Relationship:*

Signature:*

Sign or type signature:

Photo Identification *

Please take photo(s) of your government issued photo IDs and related paperwork

Let us do this part

Today's Date:

Mon Sep 7 2026 06:10

Practitioner:*