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Full name of the individual to recieve tooth gems :


In consideration of receiving a Tooth Gem from RAD INK including its artists, associates, apprentices, or any employees I agree to the following:

I understand that some of the bonding material supplied by Rad Ink may not be removed by anyone but a Dentist/Dental Hygienist and that I accept all responsibilities should I choose to use this bond for my tooth gems.
Should any gems fall off and semi bond is remaining on the tooth, I am unable to get any gems replaced until the tooth is clear.
RAD INK offers no guarantees to any length of time that for tooth gems can be made. I understand that these may last months to years and that I am to maintain excellent oral hygiene and keep the tooth as clean as possible to prevent any cavities/plaque build-up etc.
To my knowledge I do not have any allergies to any dental materials that may be used.
I have been fully informed of the risks of tooth gems including but not limited to infection and other medical complications, allergic reactions to glue, gems, latex gloves, and antibiotics. Having been informed of the potential risks associated with receiving a tooth gem, and I still wish to proceed with the procedure. I assume any and all risks that may arise from the tooth gem.
RAD INK has given me the full opportunity to ask any question about the procedure and application of my tooth gem and all of my questions, if any, have been answered to my total satisfaction.
I have been given written aftercare instructions for the tooth gem I am about to receive.
I have been informed about what I can expect following the tooth gem including medical complications that may occur following this procedure.
I understand that tooth gems can result in tooth damage and tooth loss.
I am not pregnant or nursing.
I do not have a mental impairment that may affect my judgement in getting the tooth gem.
I am not under the influence of alcohol or drugs and that I am voluntarily submitting to tooth gems without duress or coercion.
I understand there is a possibility of an allergic reaction from the tooth gem or glue applied to my teeth.
I understand there is a possibility of getting an infection, and I have been advised of the signs and symptoms of infection that indicate a need to seek medical attention.
I agree to follow all instructions concerning the care of my tooth gem.
I agree to immediately notify staff in the event I feel lightheaded, dizzy and/or faint before, during or after the procedure.
I agree that RAD INK has a NO REFUND policy on tattoos, piercing, tooth gems and/or retail sales and I will not ask for a refund for any reason whatsoever.
I am the person on the legal ID presented as proof that I am at least 18 years of age.
I release the right to any photographs taken of me and the tooth gem and give consent in advance to their reproduction in print or electronic form. (For assurance, if you do not check this provision, please inform RAD INK NOT to take any pictures of you and your completed tooth gem).
I WAIVE AND RELEASE to the fullest extent permitted by law any person of RAD INK from all liability whatsoever, including but not limited to, any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise from the procedure and application of my tooth gem, whether caused by the negligence or fault of either RAD INK, or otherwise.
I agree to reimburse RAD INK for any attorneys' fees and costs incurred in any legal action I bring against RAD INK and in which either the Artist or the Studio is the prevailing party. I agree that the courts of located in the County of Brevard within the State of Florida shall have jurisdiction and venue over me and shall have exclusive jurisdiction for the purposes of litigating any dispute arising out of or related to this agreement.
I acknowledge that I have been given adequate opportunity to read and understand this document that it was not presented to me at the last minute and grasp that I am signing a legal contract waiving certain rights to recover damages against RAD INK.
I realize that there are dental materials used to apply tooth gems and by signing this document, I release any fault of the person and business placing this tooth gem if there should be any allergic reactions or problems resulting from this application. 

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document. I hereby declare that I am of legal age (and have provided valid proof of age and identification) and am competent to sign this Agreement. I HAVE READ THE AGREEMENT, I UNDERSTAND IT, AND I AGREE TO BE BOUND BY IT.

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This is required by the health department – We hate that we have to ask this question.
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