The nature and purpose of this treatment has been explained to me and any questions I have regarding the treatment have been answered to my satisfaction.

I agree to allow pictures to be taken and shared of me.

I understand there are no refunds on services rendered or products anytime for any reason.

I understand that if I choose to reschedule or cancel my appointment I must give a 48hr notice or I will be charged the full price of the service not including any discounts or specials.

I understand that is treatment is temporary.

I understand that if my teeth or any other body part Is harmed in anyway from having this service done that I myself is responsible for all charges that will be made by a professional ( I.e Chipping, biting etc.).

I understand if I choose to have the tooth gem removed, I am responsible for any and all charges that will be made to me by a dental professional.

I accept all responsibility myself for any consequences that might stem from my decision to have any services done by adore and their employees.

I agree not to sue anyone in connection with any and all damages, claims, judgments, rights and cause of action arising from my decision I have services done by adore.

I understand that the tooth gems are applied by a licensed esthetician and not a dental professional.

I understand I will need to have them gem removed by a dental professional and accept all costs associated with the removal.

I understand there is no guarantee on how long the tooth gem will last.

I understand that all results will vary and are not guarantee.

I understand that doing any activities that could change the color of my teeth can effect the gem and the tooth under the gem, such as ( smoking, coffee, tea, teeth whitening, etc).

I understand that Tooth Jewels are non-invasive. The adhesive is the same as what a dentist uses to put on braces. The Tooth Jewels we use are 100% real Swarovski Crystal. Once the Tooth Jewel is on, there may be some dental adhesive surrounding the Tooth Jewel on the tooth. This will wear off within a couple of weeks from normal brushing and eating. If you are ready to remove your tooth jewel before it naturally falls off, it can easily be removed at your next professional routine dental cleaning. Once your tooth jewel does fall off naturally, there may still be some residual adhesive left on your tooth. This too can easily be removed at your next professional routine dental cleaning. If you use tooth whitening strips, the area under the Tooth Jewel will not receive the whitening treatment while the Tooth Jewel is on. You understand that Adore and its employees are not responsible for any damage done to your tooth/teeth during or after the Tooth Jewel procedure. Any after care of the Tooth Jewel will be done by your dental professional.

Tooth Jewels must be placed on a real and flat tooth if you have a tooth that is a false, crowned, or capped the Tooth Jewel glue will not adhere to the false tooth. The Tooth Jewel must be placed high on the tooth, or in the center, as the low part of the tooth is what sinks into food when biting I understand if I choose to have the tooth gem applied to a tooth that Is not recommended I accept the risk that it will not stay or cause damage to my other teeth.

After Care Instructions for Tooth Jewels: Do not touch or play with the crystal with your tongue or finger. You may feel the crystal inside your lips for the first few days but should get used to it after that. Do not eat or chew gum for one hour after the Tooth Jewel is placed. When you eat for the next 12 hours, softer food is better. You can drink and smoke immediately after the Tooth Jewel is placed. Do not brush your teeth you 12 hours after the Tooth Jewel is placed.

I certify that I have read this entire consent and that I understand and agree to the information provided in this form. I certify that I am competent adult of at least 18 years of age, or that, if I am a minor under the age of 18, I understand that the consent of my parent/guardian having legal custody will also be required before treatment. This agreement will remain in effect for this procedure and all future procedures conducted by Adore. I have read and fully understand all information in this agreement.

I have read and fully understand and accept this Informed Consent/Release of Liability Form and agree to accept all of the provisions and certify that the information collected is true.