Below you will find two separate forms designed to ensure your comfort, safety, and satisfaction with our services. One form is dedicated to Tooth Jewelry and the other to Eyelash Extensions. Please review and complete the form that applies to your appointment before your session begins.

General
I acknowledge that I am purchasing a self-administered Teeth Whitening Kit that is designed to whiten the color of my teeth. As a part of the purchase, I am asking for assistance in the use of my teeth whitening kit, and I understand that I will be allowed to use a specially designed LED Lamp in order to accelerate the whitening process.

Results Guarantee
Although most natural teeth can benefit from a teeth whitening treatment, I understand that everyone’s teeth are different and that results will vary. I understand that people with yellowish teeth generally get the best results and that if my teeth have spots due to tetracycline use (grayish tint) or fluorosis, these will be difficult to whiten. Also, if I have artificial teeth, caps, crowns, veneers, porcelain, composite or other restorative materials, I shouldn’t expect dramatic results from this treatment because the peroxide gel will not whiten (or damage) artificial dental work. I am also aware that my teeth will never be whiter than the white color my genes naturally allow.

Potential Risks
Although whitening treatments are generally safe, I understand that some of the potential complications of this treatment include, but are not limited to:

• Gum/Lip Irritation: Whitening gel that comes in contact with gum tissue or lips during the treatment may cause inflammation or whitening of these areas. This is due to inadvertent exposure of small areas of tissue to the whitening gel. The inflammation and/or whitening of gums and lips is temporary, and the color change will reverse within 30 minutes. A stinging or tingling sensation may be felt if gel contacts these areas.
• Tooth Sensitivity: Although uncommon, some customers may experience tooth sensitivity during the first 24 hours after the whitening treatment. People with existing sensitivity, cracked teeth, micro-cracks, open cavities, leaking fillings, exposed roots, or other dental conditions may find that sensitivity increases or lasts longer.
• Spots or Streaks: Some customers may develop white spots or streaks due to natural calcium deposits in teeth. These spots are not caused by the peroxide gel but become more visible after treatment. They usually diminish over time.
• Relapse: After treatment, it is natural for tooth color to regress gradually over time, especially when exposed to staining agents such as coffee, tea, tobacco, red wine, or colas. I understand I should not eat or drink anything except water for 60 minutes after treatment, as the gel opens the pores of enamel and makes teeth vulnerable to stains. If I purchase a touch-up pen, I understand my pores will remain open for as long as I use it and I should avoid staining agents until I stop using it. Only 24 hours after finishing the touch-up pen treatment can I resume my normal habits. I also understand that results are not permanent and that repeat or touch-up treatments may be needed to maintain my desired tooth color.

Eligibility
I understand that this treatment cannot be used by pregnant or lactating women, people under the age of 14, people with gum disease, open cavities, leaking fillings, or other dental conditions, or people with a known allergy to peroxide and/or aloe vera. People who have had braces removed should wait six months for cement residue to wear off before whitening. People with piercings or other metal objects in the oral cavity should remove them before treatment, as they may turn black. If I feel sharp pain in a tooth during treatment, I should stop immediately and contact my dentist, as this could indicate an open cavity.

Acknowledgment
By signing this document, I confirm that I meet the eligibility criteria, that I have read and fully understand the risks, complications, and benefits of the treatment, and that I am performing this treatment under my own responsibility. I also certify that I have healthy teeth and gums.

Tooth Jewel General Information and Care
Tooth Jewels are non-invasive; they don't damage the tooth or enamel and are semi-permanent. The adhesive is the same as what a dentist uses to put on braces. The Tooth Jewels we use are 100% real Swarovski Crystal. Once the Tooth Jewel is on, there may be some dental adhesive surrounding the Tooth Jewel on the tooth. This will wear off within a couple of weeks from normal brushing and eating. Tooth Jewels can last anywhere between four months to a year. If you are ready to remove your Tooth Jewel before it naturally falls off, it can easily be removed at your next professional routine dental cleaning. Once your Tooth Jewel does fall off naturally, there may still be some residual adhesive left on your tooth. This too can easily be removed at your next professional routine dental cleaning. If you use tooth whitening strips, the area under the Tooth Jewel will not receive the whitening treatment while the Tooth Jewel is on.

Tooth Jewel Replacement Guarantee
If your Tooth Gem falls off within three months of us applying it, you may bring in your original receipt along with your copy of this signed form and we will be happy to apply another for you. We are only able to replace the Tooth Jewel once.

"For long-lasting results, be sure to follow the White Diet during and after every teeth whitening." - Luis Lajous, CEO