Order Confirmation Form

THANKS FOR YOUR ORDER! LET'S CONFIRM YOUR ORDER.

PLEASE DOUBLE CHECK YOUR SELECTIONS TO AVOID DELAYS! TAKE YOUR TIME, READ, BREATHE AND TAKE IT ONE STEP AT A TIME!
YesNo
List changes being made
Agree

Please write the full name you used on your order. If you bought one for someone else, use their name for their own separate form.*

First NameLast Name
ORDER NUMBER - 4 DIGITS ONLY*

YesNo
If your order includes a free gift, please choose which teeth you want to cover. You can choose OPEN or SOLID for each tooth right next to one another. You may purchase upgrades below. If this does not apply to your order, please write N/A.*
EXAMPLE: R1 - OPEN (THIN), R2 - SOLID
Free gift on TopFree gift on BottomNo Free PMG

Can you smile really big and show your gums (the pink part above your teeth)? We need a close-up picture of that so we can check if it looks like your mouth model. It's kind of like taking a picture of your smile to see if everything is the same!*

Cancelof
YesNo
Email Address on order*
example@example.com

ACKNOWLEDGMENTS

You're almost done, but we need to know you acknowledge and understand the terms!
I understand that my order cannot enter production until acceptable dental impressions are received, and delays in submitting or correcting impressions will delay my order.
I understand that production timelines are estimates, not guarantees, and may be extended due to customization, materials, or required corrections.
I understand that minor fit adjustments are part of the custom process and do not qualify as a refund.
I confirm that my shipping address is correct and understand that EASE is not responsible for delivery issues caused by incorrect or incomplete address information.
I understand that this is a custom-made product created specifically for me and cannot be canceled, refunded, or reversed once production begins.
I understand that once my order is submitted, no changes are guaranteed, and any approved changes require a separate Order Change Request Form and applicable fees.
In the event of a cancellation or chargeback, I authorize EASE to charge my selected form of payment for this order and any approved change fees in accordance with the Terms & Conditions.

Cancellation / Liquidated Damages*

Cancellation / Liquidated Damages

If you cancel your custom order after placing it, there is a $200 cancellation fee.

We keep your card on file only for this situation — so if you cancel, don’t complete your order, or try to dispute/chargeback after we’ve already started working on it, the $200 fee will be charged to cover materials, labor, and processing already done on our end.

You are NOT being charged twice.

This fee only applies if you cancel or don’t follow through.

$200.00 Quantity

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

I acknowledge that I have reviewed my order details, understand the custom nature of this purchase, and agree to all policies outlined above and in the Terms & Conditions.
Signature of client*
Should be Empty:

THANKS FOR YOUR ORDER! LET'S CONFIRM YOUR ORDER.

ACKNOWLEDGMENTS