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!
Is this your first time filling out this form?
List changes being made
By confirming your order, you acknowledge that once your Protective Mouth Grill (PMG) is crafted according to your confirmation, you assume responsibility for any accidental discrepancies or changes.

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

Did you pay for any upgrades on your free PMG?
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
Your free gift is automatically placed on the same row as your original order. However, if you’d like it on a different row, please let us know. Keep in mind that to make this change, you’ll need to complete a new dental impression and molding kit for the correct placement.

Take a selfie of your entire smile only so that we can see the teeth you are covering with your grill.

Cancelof
Do you have a chipped or missing tooth that you're attempting to cover with your Protective Mouth Grill?
Email Address on order
example@example.com

ACKNOWLEDGMENTS

You're almost done, but we need to know you acknowledge and understand the terms!
Dental Impression Responsibility Acknowledgment
Production Timeline & Delay Acknowledgment
Fit & Adjustment Acknowledgment
Shipping & Address Responsibility Acknowledgment
Custom Product Acknowledgment
No Changes After Submission Acknowledgment
We've had a few people receive their custom piece and then file a chargeback, so we've added a card authorization to help protect the business if that ever happens.

Don't worry—you are NOT being charged. It's simply an authorization hold that's only there as a safeguard. Your card won't be billed unless there's an issue involving a chargeback on your order.

And yes, you'll still need to enter your card information to complete the authorization.
Charge Authorization - YOU ARE NOT BEING CHARGED

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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

Payment Methods
Credit Card Number	Security Code
Expiration Month	Expiration Year

Final Acknowledgment
Signature of client
Should be Empty:

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

ACKNOWLEDGMENTS

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