Please review and complete the form below before your appointment. Reach out if you have any questions.

Name(Required)

First Last

UPLOAD (Clear & Visible Photo) Of YOU Holding Your Drivers License Or Government I.D. Next To Your Face Side By Side(Required)

Max. file size: 64 MB.

Date Of Birth(Required)

MM slash DD slash YYYY

Phone(Required)

Email(Required)

Instagram(Required)

I agree to waive and release to the fullest extent permitted by applicable state law each of the and the management of from all liability whatsoever, from 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 or consequential damages, which may result or arise from the application of, or my accidental swallowing of tooth gems, weather caused by the negligence or fault of Pokes and Pouts(Required)

I Agree To Wave My Liability

I, the client certify that this Informed consent, and waiver form was completed by me and that I understand all the questions, terms and conditions, and all entries in it and information are true and complete to the best of my knowledge. I agree to observe and obey all posted, written and oral rules and warnings, including on those materials provided by Pokes and Pouts(Required)

I Agree To These Terms

I understand that the application of tooth gems and products does not include any drilling into the tooth or breaking skin and may cause marks or discoloration of my teeth. I understand that the bonding agent used to apply my tooth gem may affect my teeth, and that I have been given the opportunity to talk about the risks associated with the bonding agent with my Tooth Gem Provider(Required)

I Understand These Terms

I understand and agree that the tooth gem application procedure is semi-permanent and there is no guaranteed amount of time the products will remain on my tooth. that certain tooth gems may fall off for any or no reason after applying the gems to my teeth. I understand and agree that is not responsible for replacing or substituting any products, including any gems, white gold, crystal or gold charms(Required)

I Understand Tooth Gems Are Semi-Permanent

I understand and will follow the aftercare instructions given to me by Pokes and Pouts to ensure the longevity of my tooth gem.(Required)

I Will Follow After Care Instructions

I hereby authorize Pokes and Pouts permission to take photographs and use my likeness in a photograph or video for its promotional materials and publications, print and digital. I understand and agree that all rights to any photograph of me belong to . If you do not authorize permission to take and use your photos, you must speak to our first impressions before the service is rendered.(Required)

I Agree To Have Photos/Videos Taken

The parties will attempt to resolve any dispute arising out of or relating to this Release of Liability through friendly negotiations. If the matter is not resolved, the parties agree to using mediation(Required)

I Agree On Liability

I HAVE READ THIS DOCUMENT AND UNDERSTAND ITS CONTENTS. I FURTHER UNDERSTAND THAT BY SIGNING THIS RELEASE OF LIABILITY, I VOLUNTARILY SURRENDER CERTAIN RIGHTS. Pokes and Pouts IS NOT RESPONSIBLE FOR ANY DAMAGE CAUSED BY THE TOOTH GEM APPLICATION.(Required)

I ACKNOWLEDGE THAT I AM AGE 18 OR OLDER, HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID, THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.

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