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Tooth Removal ( Previous Clients Only)

By booking this tooth gem/ adhesive removal, I have read and acknowledged the consent form below.

  • 1 h
  • 20 US dollars
  • North 77th Street

Service Description

By booking my tooth gem/ adhesive removal, I hereby consent to the removal of the tooth gem(s)/ adhesive located on my teeth. I understand that the procedure will be performed by Zulemah Hughes, The owner of Show Me Some Teeth. I do hereby give consent to Show Me some Teeth at my request, remove my tooth gem or gold charm. I now and forever release discharge Show Me Some Teeth LLC from any costs, loss, damages or expenses arising out of the removal of my tooth or gold charm as stated above. I am aware that not all of the composite or adhesive may not entirely be removed from my tooth's surface. I have been informed of the following regarding the tooth gem removal procedure: Purpose: The purpose of the procedure is to safely remove the tooth gem(s) from the surface of my teeth. Risks: I understand that there may be risks associated with the removal procedure, including but not limited to: Potential damage to the tooth enamel or surrounding dental structures. Temporary discomfort or sensitivity during and after the procedure. Possibility The possibility of minor bleeding or irritation of the gums. Alternative Options: I have been informed of alternative options for tooth gem removal, including leaving the gem(s) in place or seeking removal from another dental provider. Consequences of Refusal: I understand that if I choose not to have the tooth gem(s) removed, there may be consequences such as potential damage to the teeth or surrounding tissues over time. Aftercare: I acknowledge that I have been provided with instructions for post-removal care, including recommendations for oral hygiene and any necessary follow-up appointments. I have had the opportunity to ask questions and have received satisfactory answers regarding the tooth gem removal procedure. I understand the information provided to me and consent to proceed with the removal.


Cancellation Policy

- You will have the option to reschedule one cancellation if you cancel your appointment within 24 hours. Deposits are non refundable.


Contact Details

  • 1717 North 77th Street, Scottsdale, AZ, USA


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