yá cult booking form
please take time to fill this out in its entirety :)
Your name
*
First Name
Last Name
Pronouns
E-mail
*
Instagram Handle
Birthday
*
-
Month
-
Day
Year
You must be 18+ to receive teeth jewelry =)
Which yá cult piece are you interested in?
Please Select
“發” Fā Tile (18k yellow gold)
“發” Fā character (18k yellow gold)
"心" Xīn character (14k YG) - Small/Large
"心" Xīn character (14k WG) - Small/Large
“中” Red Dragon Tile (18k YG)
White Dragon Tile (18k YG)
“財貓“ Cat (14k YG)
“出入平安” Black Coin (14k YG)
“出入平安“ Gold Coin (14k YG)
“四福“ Four Blessings (14k WG)
“喜” Happiness (18k YG)
“囍“ Double Happiness (18k YG)
“龍” Dragon Grill (14k YG)
Baby Foo Dog (14k White/Rose Gold)
Double Baby Foo Dog (14k White/Rose Gold)
LNY Snake Gem (14k Yellow Gold)
Peach Blossom - Star shape (14k YG)
Peach Blossom - Round shape (14k YG)
Peach Blossom Snake Grill (14k Yellow/White Gold)
Floral Snake Grill (14k Yellow/White Gold)
Regular Swarovski Tooth Crystal (various shape/sizes)
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
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