Tooth Gem Application Client Intake and Consent
Form must be completed prior to tooth gem application
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Location: 450 W 910 S  Heber City, Utah 84032. 

Description of Service

A tooth gem is a small crystal, gem, or decorative element temporarily bonded to the surface of a natural tooth using dental-grade adhesives. We are dental hygienists at Glam Studio Pros working in collaboration with a dentist to perform tooth gem application.

This is a cosmetic, non-invasive procedure and does not involve drilling, permanent alteration, or penetration of the tooth.

Todays Date *
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What is the date of your appointment? *
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Email *
First and Last Name
*also name of client if different than you (minor)
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Clients Age *
Client Date of Birth *
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Street Address, City State and Zip *
Phone Number *
Emergency Contact *
#1 Medical Conditions

I do not suffer from medical conditions or oral health deficiencies
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Required
#2 Allergies

I do not suffer from any allergies that are dental related or with adhesives.
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Required
#2a What allergy do you have
#3 Acknowlegement and Risks

By checking the box on this form, I acknowledge that:

 I am at least 18 years of age or have a legal guardian present to provide consent.

Tooth gems are for cosmetic purposes only and have no dental health benefit.

The gem is applied using dental-grade bonding material, but it is not a dental treatment and is not performed by a dentist.

Risks may include:

Temporary tooth sensitivity, gem detachment over time (average wear time varies) Possible enamel or surface changes upon removal,  allergic reaction to adhesive (rare)
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Required
#4 Professional Removal Instructions

Professional Removal Recommended — Tooth gems and/or bonding material should be removed by a licensed dentist to avoid potential enamel damage.

If the gem falls off but adhesive remains, do not pick or scrape at the tooth, contact us. We also recommend you schedule an appointment with your dentist to have the bonding material professionally polished off.  Attempting home removal may result in chipped enamel, tooth damage, or gum irritation.

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Required
#5 Care and Longevity Notice

Avoid chewing directly on the gem and limit biting into hard foods.

Continue normal brushing and flossing, taking care to brush gently over the gem.

Avoid whitening treatments while the gem is attached, as it may cause uneven coloration of the tooth

Longevity of the gem depends on individual habits, oral hygiene, and diet.

The gem may fall off at any time; this is normal and not considered a fault in the service.

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Required
Consent for Application of Tooth Gem

I have read and understood the above information. I have had/or will have the opportunity to ask questions and have them answered to my satisfaction. I consent to the application of a tooth gem and

I understand the aftercare and removal instructions. I acknowledge by signing this release I have been given the full opportunity to ask any and all questions which I might have about obtaining a semi-permanent tooth gem and all my questions have been answered to my full and total satisfaction.

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Required
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