Do you have any allergies? If yes, what are they?*

Do you wear a removable appliance? * Mouth guard (sports), night guard (for grinding/clenching), retainers, other - including dentures

Do you currently have any dental conditions or concerns that may affect your tooth gem application?* (Including gum disease, gingivitis, tooth sensitivity, bleeding gums, fillings, tooth decay, grinding/clenching, crowding, or other oral health concerns.)

Do you have any crowns, veneers, bonding, implants, or other dental restorations on the tooth you would like the gem placed on?*

Have you had your teeth professionally whitened within the past two weeks, or are you planning to have them whitened in the near future?* Recently whitened teeth can be temporarily dehydrated, and allowing time for the teeth to naturally rehydrate and stabilize may improve the success and longevity of the tooth gem application.

Do you smoke or use nicotine products (including cigarettes, vaping, or smokeless tobacco)?* Nicotine use may affect the longevity of the adhesive bond and increase the likelihood of premature tooth gem loss.

PHOTO RELEASE* Photo & Video Consent
I, the undersigned, grant permission to tiaberrys and its representatives to photograph and/or record video of my teeth, smile, and the services performed.
I understand that these images and/or videos may be used for purposes including, but not limited to:
Social media (Instagram, TikTok, Facebook, etc.)
Website and online marketing
Promotional and educational materials
Advertising and portfolio display

I acknowledge that:
My identity will not be disclosed unless I provide explicit consent.
No compensation will be provided for the use of these images or recordings.
All photographs and videos captured remain the property of tiaberrys.
I may opt out of photo and/or video use by notifying tiaberrys prior to my appointment. Choosing to opt out will not affect my ability to receive services.

Placement Consent* I authorize tiaberrys to apply a tooth gem to the tooth (or teeth) selected during my consultation.

I understand that tiaberrys only applies tooth gems to healthy, natural tooth enamel. Tooth gems will not be applied to crowns, caps, porcelain veneers, composite veneers, dental bonding, implants, or any other dental restorations.

I acknowledge that the placement of my tooth gem(s) will be discussed with the technician to help maximize retention. I understand that placement higher on the tooth or near the center of the tooth is generally recommended, as the biting edges of the teeth experience more wear and contact with food.

If I choose to have my tooth gem placed in a location other than what is recommended, I understand that the longevity of the tooth gem may be reduced, and tiaberrys cannot guarantee that it will remain attached.

I understand that certain tooth gem designs or placements may naturally have reduced retention due to their size, shape, or location on the tooth. If my selected design or placement is considered to have a higher risk of premature loss, the technician will discuss this with me prior to the procedure. In these cases, the standard 30-day complimentary reapplication policy may not apply.

Treatment Consent & Acknowledgements* I understand that tooth gems are temporary and are not intended to be permanent. With proper care, they may last up to two years+, although longevity varies depending on aftercare, oral hygiene, lifestyle habits, and other individual factors.

I have voluntarily elected to undergo the tooth gem application procedure. I have read and understand the nature of this treatment.

I understand and acknowledge that there are risks associated with this procedure. I have been informed of the possible benefits, risks, and complications, and I have had the opportunity to ask questions regarding the treatment.

I understand that placing a tooth gem in the center or upper portion of the tooth is generally recommended to help maximize retention and reduce the risk of premature loss.

I understand that my tooth gem(s) may not be compatible with removable dental appliances, including orthodontic retainers, night guards, mouth guards, expanders, grills, or similar devices. I accept responsibility for any costs associated with modifying or replacing these appliances if necessary. I also understand that attempting to force an appliance over a tooth gem may damage the tooth gem and could potentially damage my tooth enamel.

I understand that I should not attempt to remove my tooth gem myself. If I wish to have it removed, or if it naturally falls off and dental adhesive remains on the tooth, I will seek treatment from a licensed dental professional for safe removal of the tooth gem or any remaining adhesive.

Liability Acknowledgement* I acknowledge that I have read and understood the information provided in this consent form, have had the opportunity to ask questions, and voluntarily consent to receive tooth gem services from tiaberrys.

I understand that while all reasonable care will be taken during my appointment, no guarantee can be made regarding the longevity of the tooth gem or individual results. I accept the inherent risks associated with the procedure and understand that I am responsible for following the recommended aftercare instructions.

Right to Refuse or Postpone Treatment* I understand that tiaberrys reserves the right to refuse or postpone treatment if the selected tooth or oral condition is not suitable for tooth gem application, or if proceeding with the service is not considered to be in my best interest.

Service Guarantee & Refund Policy* If a tooth gem becomes detached within 30 days of application and the recommended aftercare has been followed, tiaberrys offers one complimentary reapplication. This does not include replacement of lost gems or damage resulting from trauma, misuse, accidental impact, picking at the gem, or failure to follow the provided aftercare instructions.

All tooth gem services are final. No refunds will be issued once the service has been completed.

I confirm that I have received and understand the aftercare instructions provided by tiaberrys and agree to follow them.*