Tooth Gems

Let us do this part
Today's Date:
Sat Aug 2 2025 12:46
Practitioner:*
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Please read and answer
Y
N
Eaten*
Have you eaten in the past 4hrs? Do not eat or brush your teeth for approximately 2 hours after the application.
Duress*
I affirm that I am not under the influence of alcohol or drugs, and I am voluntarily getting a Tooth Gem without duress.
Dental*
I affirm that I am not currently affected, or have not been recently affected by:
Abscess / Ulcer
Oral Herpes
Ongoing Dental Problems
Recent Dental surgery
Invisalign / Retainer
False Tooth / Veners
Halitosis
Sensitive Teeth
Maternity*
I affirm that I am not pregnant and I am not breastfeeding.
Health*
I affirm that I have not experienced any vomiting, diarrhoea or any form of virus or infection in the last 48 hours.
Removal*
I understand that, once applied, the tooth gems cannot be removed the Tooth Gem technician. They can be removed by a dentist or hygienist, during a routine scale and polish, or I can wait until they fall down on their own.
Confirm*
I confirm that i am of sound mind and agree to follow the aftercare provided.
I understand that my tooth gem can last anywhere from one month to a couple of years, depending on how well I look after them and to achieve longevity I must follow the aftercare instructions.
I understand that by going ahead with the treatment all information provided is correct and I am going ahead at my own discretion.
ID Check
I confirm that I have presented valid government issued photo ID to a member of Piercer Charlie's Creations staff.
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:*
Address:
Postcode:
Date of birth:*
If you are under 18 your parent/guardian will be required
Phone #:
Email:*
Signature:*


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