yá cult booking form

yá cult booking form

please take time to fill this out in its entirety :)
Your name*

First NameLast Name
Pronouns
E-mail*
Instagram Handle
Birthday *

MonthDayYear
You must be 18+ to receive teeth jewelry =)
Which yá cult piece are you interested in?
What is your $$ budget per tooth (USD)?*
Which tooth/teeth do you want the jewelry bonded to? Please also take a picture and point to the tooth/teeth and attach it below.*
Do you have an appliance that you wear during the day or night? (e.g. Invisalign retainers, night guard, orthodontic retainer). Please describe below and take a picture of you wearing it.
Do you have any allergies, or have you had any adverse reactions to any dental materials? (e.g. Latex, metals, acrylics…etc)
Are you interested in professional whitening for an additional fee? (Note: professional whitening will have to be done a minimum of 10 days for color stabilization before tooth jewelry application).

Yes (I will have a certified dental assistant reach out to your email with details)No
Upload your pictures

You can upload your reference pictures, pics of your tooth/teeth... (Max size:300MB)
Cancelof
List your availability dates :)
How did you hear about us?*
Please click to read the FAQ.
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