Tooth Gems Release Form

Basic Info:

Today's Date:

Mon Jun 22 2026 07:31:21

Artist:*

How did you hear about us?:*

Please read & answer:

Release*

I, the “client,” agree to observe and obey all posted, written, and oral rules and warnings, including those on materials provided by my service provider or on the premises.

By signing this Release, I have been given the full opportunity to ask all questions that I might have about obtaining a tooth gem, and all my questions have been answered to my complete and total satisfaction. I acknowledge I have been advised of the matters set forth below, and I agree as follows:

Veneers/Crowns & Tooth Gem Removal*

My tooth is free of previous crystals/bond, and it is a natural tooth. I understand, the bonding agent will not attach to existing bond or false teeth/veneers/crowns/dental composite. I understand Cherry Bomb cannot remove crystals/bond at the time of my service; a dentist must do it beforehand.

I understand that if I would like the tooth gem or charm removed, I must go to a dentist. If the tooth gem or charm falls off and there is only bond left, that must also be removed by a dentist.

Dental Hygiene *

I should continue to see a dentist regularly to maintain proper oral health and hygiene for my teeth. I have been advised to contact the dentist immediately to remove all residue from the bonding agent if my tooth gem or charm falls off.

I have been advised not to bleach or perform blue light whitening procedures on my teeth because they may affect the bonding agent used to apply my tooth gem or charm.

Informed Consent*

I have trustfully represented to the Tooth Gem Artist that I am over the age of 18 years. I am not under the influence of drugs or alcohol. To my knowledge, I do not have any physical, mental, or medical impairment or disability which might affect my well-being as a direct or indirect result of my decision to have a tooth gem done at this time.

Both the Artist and the Studio have given me the full opportunity to ask all questions about the tooth gem procedure, and they have been answered to my total satisfaction.

I affirm that I am not under the influence of alcohol or drugs and voluntarily getting a tooth gem without duress.

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 that I am signing a legal contract.

Permanence*

I understand that the tooth gem or charm application procedure is semi-permanent, and the products will not be guaranteed to remain on my teeth.

I understand that certain tooth gems or charms may fall off for any or no reason after applying them to my teeth. I understand and agree that neither my tooth gem technician nor Ro Bataille, LLC is responsible for replacing or substituting any products, including gems, diamonds, or gold charms, if my tooth gem or charm falls off.

Risks*

I understand that a light curing procedure may cause calcium spots to appear on my teeth, and applying tooth gems may cause marks or discoloration.

I understand that the application process of tooth gems and charms may affect my tooth enamel, and I have been allowed to talk about the risks associated with my tooth gem technician and my dentist.

Further, I understand that the bonding agent used to apply my tooth gem or charm may affect my teeth. I have been allowed to talk about the risks associated with the bonding agent with my tooth gem technician and my dentist.

Aftercare*

I understand and will follow the aftercare instructions given to me by the tooth gem technician or Ro Bataille, LLC, to ensure the longevity of my tooth gem or charm.

Indemnification*

I agree to indemnify and defend Ro Bataille, LLC, Iron Cherry, LLC, Cherry Bomb Studio, my service provider, as well as any representatives, employees, contractors, and agents against all claims, causes of action, damages, judgments, costs, or expenses, including attorney fees and other litigation costs, which me in any way arise for my use of or presence upon the facilities of Cherry Bomb Studio located at 231 Eldridge Street.

I agree to release and forever discharge and hold the Cherry Bomb Studio and all employees harmless from all claims, damages, or legal actions arising from or connected with my tooth gem or the procedure and conduct used in my tooth gem.

I agree to waive and release to the fullest extent permitted by law each of the Artist and the Studio from all liability whatsoever for any claims or causes of action that I, my estate, heirs, executors, or assigns may have for personal injury or otherwise, including any direct and consequential damages, which result or arise from my tooth gem, whether caused by the negligence or fault of either the Artist or the Studio, or otherwise.

I agree to reimburse each of the Artist and the Studio for any attorneys' fees and costs incurred in any legal action I bring against either the Artist or the Studio and in which either the Artist or the Studio is the prevailing party. I agree that the courts of New York shall have personal jurisdiction and venue over me and shall have exclusive jurisdiction for litigating any dispute arising out of or related to this agreement.

Unenforceability*

I understand Release of Liability or unenforceability of any provision of this Release of Liability shall not affect any other condition in this Release of Liability or other applications of such provision, and such unenforceable provision shall be deemed not to be part of this Release of Liability.

Mediation*

I agree that the parties will attempt to resolve any dispute arising from or relating to this Release of Liability through friendly negotiations. If the matter is not resolved, the parties agree to use mediation.

Payments*

I have read and agree with the pricing and policies.

Payment will be made to the Business via cash, or any other payment method determined by the Business.

I understand that my final price may differ from what is reflected in this appointment booking due to either error while booking or additional, less, or other services provided.

After completing my service, I agree to pay the remainder of the total final price calculated and requested. If I have questions about pricing, I will ask for that information before my appointment begins.

Unless previous arrangements are made, if I refuse to pay the requested amount at the time of service, my card on file may be charged that amount, and Ro Bataille, LLC will provide me with an itemized receipt of the charges.

No Refunds*

The Customer will be assumed to have accepted the Goods unconditionally. The deposit and final charge are non-refundable. No refunds will be provided for the work completed or services performed under this Contract.

Authority*

Each party has the authority to enter this Contract and perform all its obligations under it.

Signatures*

This Contract may be signed electronically or in hard copy. Electronic signatures count as original for all purposes.

Changes*

The Client and the Business must agree to any changes to this Contract in writing.

Acknowledgement*

I have read this document and understand its contents. I acknowledge that the information I gave in this form is accurate and complete. I know that I voluntarily surrender certain rights by signing this Release of Liability. By signing below, I confirm that I understand and agree to all terms and statements in this form.

I certify that I am a competent adult of at least 18 years of age. This consent form is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representatives, heirs, administrators, successors, and assigns.

I have read and understand this agreement. The nature and purpose of the treatment have been explained to me. All my questions have been answered to my satisfaction, and I consent to the terms of this agreement.

By signing your name as a signature below, you agree to the terms and provisions of this agreement.

Photo Release*

I release all rights to any photographs taken of me and the tooth gems and/or charms and give consent in advance to their reproduction in print or electronic form or in any new media. I permit to use of my photos for marketing. My pictures may appear in print or online or new media. (If you choose NO this provision, please advise your Artist).

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.

Personal Info

I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.

Name:*

Address:*

Date of birth:*

Phone #:*

Email:*

Signature:*

Photo ID(s)*

Please take a picture of your government issued photo ID