Tooth Gem Aftercare Instructions Form
Please complete this form to acknowledge receipt and understanding of your tooth gem aftercare instructions. Your responses help us provide the best care and support.
Full Name
*
First Name
Last Name
Appointment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Tooth Gem Placement (e.g., upper right canine)
*
Have you received and read the tooth gem aftercare instructions provided?
*
Yes, I have received and read the instructions
No, I have not received the instructions
How do you plan to clean your teeth after the tooth gem application?
*
Which food or drink precautions were you advised to follow after your appointment?
*
Avoid hard or sticky foods for 24 hours
No hot drinks for 2 hours
Avoid acidic beverages for 24 hours
Other
What potential issues should you watch for after your tooth gem application?
*
Gem feels loose or falls off
Irritation or discomfort in the area
Swelling or redness
Other
How would you prefer to receive follow-up support or reminders?
Email
Phone call
Text message
No follow-up needed
I confirm that I understand the tooth gem aftercare instructions and agree to follow them.
*
I confirm and agree
I do not agree
Submit
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