yá cult custom booking form
please take time to fill this out in its entirety :)
Your name
*
First Name
Last Name
Pronouns
E-mail
*
Instagram Handle
Birthday
*
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Month
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Day
Year
You must be 18+ to receive teeth jewelry =)
Provide a detailed description of your custom piece:
*
Please provide as much info as possible for me to better understand your custom piece concept, including pictures below. Custom pieces require a minimum of 2 weeks for design and creation of the piece.
What is your $$ budget per tooth?
*
What karat gold for your piece?
Please Select
14 karat yellow gold (14k YG)
18 karat yellow gold (18k YG)
14 karat white gold (14k WG)
18 karat white gold (18k WG)
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
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You can upload your reference pictures, pics of your tooth/teeth... (Max size:300MB)
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List your availability dates :)
*
How did you hear about me?
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