Dove Esthetics - Paloma T. Pahle-Levesque

TOOTH GEM APPLICATION WAIVER & RELEASE OF LIABILITY (OREGON)

Full Name *

Phone Number *

Date of Birth

Allergies or Medical Conditions *

Include skin conditions, allergies, medications, or anything we should know

I am not currently pregnant or nursing

Some treatments may not be suitable during pregnancy

INHERENT RISKS INCLUDING BUT NOT LIMITED TO:

MEDICAL & DENTAL DISCLOSURE:

NO WARRANTY OR GUARANTEE

AFTERCARE RESPONSIBILITY:

RELEASE OF LIABILITY:

HOLD HARMLESS & INDEMNIFICATION:

LIMITATIONS (OREGON LAW):

COVENANT NOT TO SUE:

SEVERABILITY:

Photo & Social Media Consent *

May we photograph your results and share them on our social media or website?

Client Signature *

Sign here

By signing, you acknowledge the information above is accurate