I understand that a tooth gem is a cosmetic procedure in which a small jewel or decorative gem is bonded to the surface of a natural tooth using dental bonding materials.

I understand and acknowledge the following:

• The procedure is purely cosmetic and provides no medical or dental benefit.

• The procedure does not involve drilling or permanent alteration to the tooth enamel during standard application.

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• Tooth gems are temporary and longevity varies widely depending on oral habits, tooth structure, and aftercare.

• The gem may remain in place for days, weeks, or months, but may also detach at any time.

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Dental-Grade Adhesive Disclosure

I understand that the technician may use professional dental bonding materials and adhesives intended for cosmetic dental applications.

I acknowledge the following:

• The technician performing this service is not a licensed dentist or dental hygienist unless otherwise stated.

• The technician is providing a cosmetic service only and is not diagnosing, preventing, or treating dental conditions.*

• Dental bonding materials are designed to adhere to enamel and may require professional removal by a dentist.

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Possible Risks & Complications

Although tooth gem application is generally considered a low-risk cosmetic procedure, I understand the following risks may occur:

• Tooth sensitivity

• Gum irritation

• Plaque buildup around the gem

• Staining or discoloration around the bonded area

• Damage to enamel if the gem is forcibly removed

• Chipping or weakening of enamel if improper removal occurs

• Accidental swallowing of the gem if it becomes dislodged

I understand that these risks are uncommon but possible.*

Client Responsibilities & Aftercare

I agree to follow all aftercare instructions provided to me, including but not limited to:

• Avoiding hard, crunchy, or sticky foods for the first 24 hours

• Avoiding picking, biting, or playing with the gem

• Maintaining proper oral hygiene including brushing and flossing

• Avoiding using teeth to open packages or bite hard objects

Failure to follow aftercare instructions may result in premature loss of the gem or other complications.*

Removal of Tooth Gems: I understand the following regarding removal:

• Tooth gems may fall off naturally without notice.

• If removal is desired, it is recommended that removal be performed by a licensed dental professional.

• Attempting to remove the gem myself may damage tooth enamel.*

No Guarantee of Longevity: I understand that the technician and studio make no guarantees regarding how long the tooth gem will remain attached. Longevity depends on factors outside the control of the technician including chewing habits, oral hygiene, and tooth structure.*

Colorado Liability Release & Assumption of Risk

I acknowledge that cosmetic tooth gem services involve inherent and potential risks.

By signing this agreement, I voluntarily assume all risks associated with the procedure.*

To the fullest extent permitted under Colorado law, I hereby release, waive, discharge, and hold harmless Solana Tattoo, Solana Tattoo Company/Marked Collective, its owners, managers, employees, independent contractors, technicians, apprentices, agents, and affiliates from any and all liability, claims, demands, damages, actions, or causes of action of any kind arising out of or related to the tooth gem procedure.*

I consent to photos

I do not consent to photos

Certification and Informed Consent

I certify that:

• I have read and fully understand this entire consent form.

• I have had the opportunity to ask questions and all questions have been answered to my satisfaction.

• I understand the risks associated with this cosmetic procedure.

• I voluntarily consent to the application of a tooth gem.*