Tooth Gem Agreement & Consent Form

I

, authorize ‘Tamaria.L’ of ‘Bling & Beauty Salon’, a trained and tooth gem professional certified in the state of ‘Georgia’ hereinafter collectively referred to as my gem tech, to perform a tooth gem procedure.

I understand this procedure requires lead free Swarovski crystals to be adhesively applied to my tooth. I acknowledge that my gem tech has explained to me the methods and procedures concerning the application of a tooth gem.

I hereby consent to the procedure at my own risk. If at any time I am uncomfortable with the gem application, I will inform my gem tech and she will use good faith efforts to rectify the problem, including ending the session if I or my gem tech wish. If my gem tech is uncomfortable applying gems on me, she will discuss her concerns with me and may end the session if necessary.

I understand that the duration of my gem requires my careful maintenance. I understand that it takes 24 hours for the adhesive to cure thoroughly and avoiding contact with the gem to eliminate the risk of interference with this curing process, which may result in a weaker bond and/or the gem falling off sooner then planned. I also understand after the first 24 hours post application, if I participate in any of the following or any other activities that may interfere with the tooth gem such as; eating foods before the 2 hour window, brushing teeth before the 12 hour window, using an electric tooth brush before the 48 hour window, and lastly not complying with eating soft foods for the first 24 hours. I understand that failure to follow these instructions may cause the loss off my gem/s sooner than planned. I understand that the gem application and the post application care and maintenance described herein I will follow through by.

I, THE UNDERSIGNED, HEREBY FULLY RELEASE, WAIVE, COVENANT NOT TO SUE, AGREE TO HOLD  HARMLESS, AND FOREVER DISCHARGE my gem tech, ‘Tamaria.L’ of ‘Bling & Beauty Salon’, from any and all liabilities, demands, claims, losses, injuries, or damages, including court costs and attorney’s fees and expenses, of  any kind arising out of, or relating to, the application of tooth gem products, EVEN IF, THOUGH CAUSED IN WHOLE OR IN PART BY A PRE EXISTING DEFECT, THE NEGLIGENCE, WHETHER  SOLE, JOINT, OR CONCURRENT, GROSS NEGLIGENCE, STRICT LIABILITY OR OTHER LEGAL FAULT OF  MY TECH. IT IS MY EXPRESS INTENT THAT THE ABOVE RELEASE INCLUDES THE RELEASE OF MY GEM TECH FROM THE CONSEQUENCES OF THEIR OWN NEGLIGENCE.

It is also my express intent that this Waiver and Release Form shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representatives, if I am deceased, and shall be governed by the laws of the State of ‘Georgia’.

I further agree that, should I choose to seek the advice of an attorney regarding said release, I will be responsible for any and all costs of legal services that I incur. I agree that this release shall be in contemplation of any possible damages, either known or unknown at the signing of this Waiver and Release form, and said damages are specifically waived following the signing of this waiver and release form. I further agree that in the event that any dispute that arises out of, or relating to, the application of tooth gem products and or terms of this Waiver & Release between me, or anyone acting on my behalf, my gem tech and or anyone affiliated with my gemtech shall be resolved by binding arbitration before the American Arbitration Association. The exclusive venue for arbitration against my gem tech shall be the city and state in which the gem tech resides at the time the arbitration is initiated. I agree that I will be responsible for and will pay all court costs, arbitration costs, attorney fees and expenses, and other associated costs incurred by my gem tech, in seeking enforcement of this Waiver & Release.

I further release my gem tech from any responsibility for preexisting conditions I have not revealed, or any consequential change to those conditions that arises subsequent to the procedure. I understand that I am responsible for any medical treatment I may need to receive as a result of getting this procedure. I accept full responsibility for these and any other complications, which may arise or result during or following the tooth gem procedures, which are to be performed at my request.

I, the undersigned client, certify that I have read, had explained to me and fully understand the above Waiver and Release form and am signing it voluntarily as my own free act and deed. I certify that I have consulted with a gem tech and have read all applicable literature given to me. I certify I am of sound mind and I am fully capable of executing this Waiver and Release form for myself. No oral representations, statements, or inducements apart from the foregoing agreement that has been reduced to writing have been made.

I, the undersigned client, acknowledge and fully understand that there might be other known risks not reasonable foreseeable at this time. I, undersigned client, acknowledge that I have read and agree to the provisions, terms, and conditions provided in this Waiver and Release Form. I agree to assume all risks that may be associated with the application, and agree to hold harmless the gem technician and ‘Bling & Beauty Salon’.

I, the undersigned client, hereby give ‘Bling & Beauty Salon’ the absolute right and unrestricted permission to take, use, and display photogenic images of me, through any form of media, print, digital, electronic, broadcast, or otherwise, at any location for art, advertising, media release news articles, marketing, publicity, archival, or any other lawful purpose. I waive any right to royalties or other compensation arising from or related to the use of photogenic images of me. I release and agree to hold harmless ‘Bling & Beauty Salon’ and the gem technician from any liability in connection to taking or using said images.

Check yes or no below for image consent. (TEETH/MOUTH)

Full Consent to procedure and acknowledgement of Waiver for Tooth Gem service. Minors should be accompanied by a parent or guardian and form should be filed out by the parent/guardian on the minors behalf.

CLIENT IN-TAKE (Below For Technician Only)

GEM Color:_________________________________________________________________

GEM Size:__________________________________________________________________

Tooth Selected:______________________________________________________________