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Tooth Gem Consent Form

Birthday

I have completed the form to the best of my knowledge and ability. I agree to inform the technician of any changes in the above information. I agree that I do not have any conditions that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow that to adjust accordingly. I agree to waive all liability toward my technician for any injury or damages incurred due to any misrepresentations of my health.

Date

By signing below I agree that I have read and fully understand this agreement and all information detailed above I understand the procedure and accept the risks. I agree I will assume the risk and full responsibility for any and all injuries, losses, side effects or damages that might occur to me while I am undergoing this procedure. I do not hold the technician, Glitter Gaud Hayla Myke, NIKE or Makeway INC. responsible for any of my conditions that were present but not disclosed at the time of this procedure, which may be affected by the treatment performed today. 


Date
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