Tooth Gem Release Form Release Form
Let us do this part
Fri Nov 15 2019 05:01
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I understand that Five and Dime Tattoo and it's agents make no claims, warranties, or guarantees as to the safety of any materials including but not limited to the jewelry itself, glues or any other products used in the application of the tooth gem.
I understand that having this service is temporary.
I understand that if my Tooth Jewelry falls out for any reason except mistreatment or failure to properly follow aftercare guidelines during the two weeks following the procedure, it will be replaced at no charge. After two weeks there is no guarantee, or warranty of replacement. If I wish to have another tooth jewelry installed, I will bear the cost of the service and jewelry myself.
If my teeth or any other body part, is harmed in any way from having this service done, I myself will be responsible for any and charges that will be made to me for the repairs by a professional. (I.e. chipping, biting, etc.)
If in the event I no longer wish to have my tooth jewelry, I myself will be responsible for all charges that will be made to me by a dental professional in the removal of my tooth jewelry.
Being of sound, mind and body, I hereby release any and all persons representing Five and Dime and their agents from ALL responsibility.
I accept any and all responsibility myself for any consequences that might stem from my decision to have any services, or any related work done by Five and Dime and their agents.
I agree to not sue anyone in connection with any and all damages, claims, judgments, rights and causes of action arising from my decision to have services from Five and Dime , whether or not caused by any negligence of anyone.
I agree for myself and my heirs, assigns, and legal representatives to hold Five and Dime and their agents harmless from all damages, actions, causes of actions, claims, judgments, cost of litigation, attorney fees and any other costs and expenses which arise from my decision to have services/ and or related work done by anyone Five and Dime and their agents.
I agree to pay for all damages and injuries to any and all persons and property belonging to Five and Dime, and any persons to whom Five and Dime may become liable contractually or by operation of law caused by, or resulting from any decision to have any services/ and or related work done by anyone representing Five and Dime.
I agree to leave the premises of Five and Dime or any other establishment where Five and Dime is engaged in business, promptly upon request, for any reason whatsoever, by any agent or employee of Five and Dime , at any time.
I agree that these waivers also pertain to and are designed to protect any and all establishments where Five and Dime conducts business.
I agree to have ALL pertinent documents copied and given to Five and Dime for records.
I agree to follow aftercare guidelines that are provided to me verbally or in writing until healing is complete.
I am in full understanding that the services being performed, may result in permanent changes to my body and no claims have been made regarding the ability to undo any changes made.
I am in full understanding that misrepresentation, falsifying of any information provided by me is a crime and I can be subject to prosecution.
I have read/signed all sections of paperwork to its entirety.
I further state and certify that I am an adult over the age of 18, not intoxicated or under the influence of any drugs or alcohol, illegal substances, narcotics whether legal or illegal, and make these and all statements fully and completely of free will and sound mind.
I hereby release Five and Dime and its agents from all manners of liabilities, claims, actions, and demands, in law or in equity, which I or my heirs might now or in the future, by any reason of complying with my request to have services by Five and Dime and it's agents.
All tooth gem sales and procedures are final. No refunds No exchanges.
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.
Date of birth:
If you are under
your parent/guardian will also need to fill out the guardian section.
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I, as parent or legal guardian of the above minor under 18 years of age, hereby consent to the terms and conditions set forth in this release form.
For tooth gem of minors: I agree to have all documents stating parental or legal guardianship such as: 1)Birth Certificate 2) Government Issued ID card from minor/parent3)School ID Card from minor in the event there is not a Government ID is not present.
Natural guardian (birth parent)
Legal parent via marriage
Legal guardian via adoption
Other (provide proof)
Notary (let us do this)
Please take a picture of your government issued photo ID