The Tooth Gem Consent Form is an essential legal document required for cosmetic dental procedures in Switzerland. It serves as a formal agreement between the service provider and client, documenting informed consent for the application of decorative gems to dental surfaces. This document is particularly important given Switzerland's strict regulations regarding medical and cosmetic procedures, requiring detailed documentation of risks, procedures, and aftercare instructions. The form should be used before any tooth gem application procedure and must comply with both federal Swiss healthcare regulations and canton-specific requirements. It includes comprehensive sections covering medical history, procedure details, risk acknowledgment, and client responsibilities, while ensuring compliance with Swiss data protection laws. The document may need to be available in multiple Swiss national languages to ensure proper understanding by all clients.
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1. Client Information: Personal details of the client including name, date of birth, contact information, and emergency contact
2. Service Provider Information: Details of the practitioner and establishment performing the procedure
3. Medical History: Questionnaire regarding relevant medical conditions, allergies, and dental history
4. Procedure Description: Detailed explanation of the tooth gem application process, materials used, and expected duration
5. Risks and Complications: Comprehensive list of potential risks, side effects, and complications associated with tooth gem application
6. Client Responsibilities: Client's obligations regarding aftercare and maintenance
7. Practitioner Declarations: Statements confirming practitioner qualifications and safety protocols
8. Financial Agreement: Cost of the procedure and payment terms
9. Consent Declaration: Formal statement of informed consent and acknowledgment of understood risks
10. Signatures: Space for client and practitioner signatures with date
1. Parental Consent: Additional consent section for clients under 18 years of age
2. Photo Release: Optional authorization for before/after photographs and their use
3. Insurance Declaration: Statement regarding insurance coverage and liability
4. Cancellation Policy: Terms and conditions for appointment cancellation and rescheduling
5. Translation Declaration: For non-native speakers, confirmation that the form was understood in their preferred language
1. Aftercare Instructions: Detailed guide for post-procedure care and maintenance
2. Product Information Sheet: Technical information about the gems and adhesives used
3. Price List: Detailed breakdown of costs for different gem types and services
4. Medical History Form: Detailed questionnaire about client's medical and dental history
5. Before/After Photos: Visual documentation of similar procedures for reference
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