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Tooth Gem Consent Form

This form must be filled out prior to arriving for your tooth gem session.

Upload Photo of DL or ID

Teeth Whitening Consent Form

This form must be filled out prior to arriving for your whitening session.

Upload Photo of DL or ID

COVID-19 Addendum

This form must be filled out prior to arriving for your tooth gem session.

Do you knowingly and willingly consent to receiving tooth gem services during the COVID-19 pandemic?
Do you inderstand that the COVID-19 virus has a long incubation period, during which carriers of the virus may be asymptomatic yet highly contagious. Given the current conditions of diagnostics, it is not possible to determine who is or is not actively virulent.
Do you understand that due to the nature of tooth gem application, I have an elevated risk of exposure by proceeding with the tooth gem?
Do you confirm that you are not presenting any of the following symptoms of COVID-19: Fever, Shortness of Breath, Loss of Taste or Smell, Dry Cough, Runny Nose, or Sore Throat?
To help prevent the spread of COVID-19 and ensure the best practices, do you agree to follow the guidelines and protocols outlined by Houston Tooth Gems?
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