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Tooth Gem Consent Form
Let us do this part
Today's Date:
Sat Apr 4 2026 01:02
Practitioner:*
Signature:*

Tooth Gem Consent Form
Please read and answer
Y
N
Do you have any allergies or sensitivities to dental materials?
Details: 
Y
N
Do you have any false, crowned, or capped teeth or veneers?
Details: 
Y
N
Do you have sensitive teeth?
Details: 
Y
N
I agree that I am over the age of 16, am NOT under the influence of alcohol or drugs, am NOT pregnant or nursing and desire to receive the teeth gem procedure. The general nature of the teeth gem procedure has been explained to me.
Y
N
I have been informed of the nature, risks, and possible complications and consequences of the tooth gem procedure including but not limited to allergic reaction to adhesive /bonding agent, negative affects on tooth enamel, and swallowing the gem or jewel.
Y
N
I understand that tooth jewels/gems must be placed on a real and flat tooth.
Y
N
I understand that tooth jewels/gems are non-invasive and are semi-permanent.
Y
N
I understand that some dental adhesive may appear around the tooth gem and surrounding area(s). The excess dental adhesive will wear on within a few weeks from normal brushing and eating.
Y
N
I understand that tooth jewels/gems may last between 1 month and 1 year. Your tooth gem can be removed by your dental professional if you wish to remove your tooth jewel/gem prior to it naturally falling off and Samsara Ink is not responsible for any charges or fees as a result of removing the tooth jewel/ gem.
Y
N
I understand that when my tooth jewel/gem naturally falls off, there may be some residual dental adhesive left on the tooth. The dental adhesive can easily be removed at my next routine dental cleaning.
Y
N
I understand that I may use teeth whitening strips but the area beneath and surrounding my tooth
jewel/gem may not lighten.
Y
N
I understand that if my tooth jewel/gem falls off prematurely (before 1 month), I will contact Samsara Ink to schedule a replacement. I further understand that only 1 replacement will be given in such incident
Y
N
I understand that Samsara Ink and associated employees are not responsible for any damage done to your tooth/teeth during or after the Tooth Gem procedure and any aftercare required will be done by your dental professional.
Y
N
I understand that all services and deposits are not refundable.
Y
N
I elect to receive this procedure from Samsara Ink on my own free will and understand and accept all of the above information.
I understand this agreement is binding and that I have read and fully understand all information listed above. I represent that I am over the age of 18 or it under the age of 18, I have a parent and /or guardian signature below and that he/she consents to this procedure under these terms. I have completed this form to the best of my ability and knowledge and agree to inquire about questions i may have before Samsara Ink begin performing the procedure. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform my technician of any discomfort I may experience during the requested treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my technician and Samsara Ink for any injury or damages incurred due to any misrepresentation of my health history.
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
Age: 
Phone #:*
Email:*
Signature:*

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