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Please read the following and fill out each provision on the line provided to show that you understand and agree to the provision. In consideration of both (a)receiving a tooth gem, gold charm, or similar tooth gem product from the Tooth Gem Technician and (b) the use of facilities provided by The Tooth Gem Lounge and its employees, you agree to the following:

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

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