Tooth Gem Consent & Waiver Form

If you’ve reached this page, you’re just about to LEVEL UP with some tooth gem badassery! Please fill out the following form to the best of your ability including your signature at the bottom.

As always, if you have any questions, please do not hesitate to ask me before we get started with the procedure!


    CONTACT INFO:


    PROCEDURE VERIFICATION


    CONSENT, RELEASE OF LIABILITY, & CLAIM WAIVER

    Please the following consideration of receiving a tooth gem, gold gem, or similar tooth gem product from the Tooth Gem Technician, Avani Joy Visone, and the use of facilities provided by Root & Crown (Raging Roots Studio LLC) and its employees, you agree to the following:

    1. I certify that this informed consent and waiver form was completed by me the aforementioned, and I confirm that I understand all the questions, terms, and conditions, entries in it and the information herein is complete to the best of my knowledge. I agree to observe and obey all posted, written, and oral rules and warnings, including on those materials provided by Root & Crown.

    2. I agree to waive and release to the fullest extent permitted by applicable state law of the tooth gem technician, all employees, contractors, and the management of the studio where services are being rendered from all liability whatsoever, for any and all claims or causes of action that, my estate, heirs, executors, or assigns may have for personal injury or otherwise, including any direct or consequential damages, which result or arise from the application of or my accidental swallowing of tooth gems whether caused by negligence or fault of the tooth gem technician.

    3. I am 16 years or older.

    4. I understand that the application of tooth gems and associated products does not include any drilling into the tooth or breaking the skin and may cause marks or discoloration of my teeth especially if I do not maintain proper dental hygiene following placement of tooth gems.

    5. I understand that the application of tooth gems may affect the enamel of my tooth/teeth and I have been given the opportunity to talk about the risks associated with my tooth gem products with my tooth gem technician and dentist.

    6. I understand that the bonding agent used to apply my tooth gem may affect my teeth and I have been given the opportunity to talk about the risks associated with the bonding agent with my tooth gem technician and dentist.

    7. I understand and agree that the tooth gem application procedure is semi-permanent and there is no guaranteed amount of time that products will remain on my teeth.

    8. I understand that certain tooth gems may fall off for any or no reason after applying the gems to my teeth. I understand and agree that Root & Crown (Raging Roots Studio LLC) is not responsible for replacing or substituting any products, including any gems, diamonds, or gold charms, if my tooth gem falls off after 1 week or placement.

    9. I understand that I should continue to see a dentist regularly to maintain proper oral and dental health and hygiene for my teeth.

    10. I have been advised that I should contact a dentist to remove all residue from the bonding agent from my tooth if my tooth gem falls off or if I wish to remove it.

    11. I understand and will follow the aftercare instructions given to me by the tooth gem technician to ensure the longevity of my tooth gem.

    12. I hereby authorize Avani Joy Vison, my tooth gem technician, and the studio permission to take photos and use my likeness in photography or video for its promotional materials and publications, print and digital. I understand and agree that all rights to any photos of me belong to Root & Crown (Raging Roots Studio LLC).

    13. The invalidity or unenforceability of any provision or this Release of Liability shall not have any effect of any other provision of this Release of Liability or of any other applications of such provision, and such unenforceable provision shall be deemed not to be a part of this Release of Liability.

    14. The parties will attempt to resolve any dispute arising out of or relating to this Release of Liability through friendly negotiations. If the matter is not resolved, the parties agree to use mediation.

    I understand that there are NO exchanges or refunds for services provided.

    I HAVE READ THIS DOCUMENT AND UNDERSTAND ITS CONTENTS. I FURTHER UNDERSATND THAT BY SIGNING THIS RELEASE OF LIABILITY, I VOLUNTARILY SURRENDER CERTAIN RIGHTS. ROOT & CROWN (RAGING ROOTS STUDIO LLC) IS NOT RESPONSIBLE FOR ANY DAMAGE CAUSED BY TOOTH GEM APPLICATION.