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Tooth Gem
Let us do this part
Today's Date:
Sat May 2 2026 07:12
Practitioner:*
Please read and answer
Y
N
I acknowledge by signing this release that I have been given the full opportunity to ask any and all questions which I may have about obtaining a tooth gem by MARAH LANDRY and all questions have been answered to my full and total satisfaction.
Y
N
I have completed the COVID waiver prior to coming in for my appointment.
Y
N
I understand that there is no drilling into my tooth or breaking of my skin. However, the application and bonding agents used may affect my tooth enamel, cause discoloration or marking.
Y
N
I understand that the procedure/application is semi-permanent and there is no guaranteed amount of time that the gems or products will remain on my teeth.
Y
N
I understand that some gems/products may fall off for any or no reason and MARAH LANDRY is not responsible for replacing them.
Y
N
Inunderstand that I should maintain oral cleanliness and hygiene by visiting my dentist regularly.
Y
N
I understand that bleaching or using a blue light whitening procedures may affect the bonding agents and potentially the gems.
Y
N
I understand that I should contact my dentist to remove any and all product/residue if I wish to remove my tooth gems.
Y
N
I understand and agree to follow the provided aftercare instructions given to me.
Y
N
I give consent in advance to have my photograph taken and the potential reproduction in print or electronic form.
Y
N
I agree to waive and release to the fullest extent permitted by law MARAH LANDRY and PHENIX SALON SUITES from all liability whatsoever, for any and all claims/causes of action that I, my estate, heirs, executors or assigns may have for personal injury and/or damages, whether caused by the negligence or fault of either MARAH LANDRY or PHENIX SALON SUITES, or otherwise.
 
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.
Legal Name:*
Pronouns:
Chosen name:
Address:*
Postcode:*
Date of birth:*
 
If you are under 18 your parent/guardian will be required
Age: 
Phone #:*
Email:*
Signature:*

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