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?*

YesNo
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.*

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*

Did you pay for any upgrades on your free PMG?*

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
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.*

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
Do you have a chipped or missing tooth that you're attempting to cover with your Protective Mouth Grill?*

YesNo
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*

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.
Production Timeline & Delay Acknowledgment*

I understand that production timelines are estimates, not guarantees, and may be extended due to customization, materials, or required corrections.
Fit & Adjustment Acknowledgment*

I understand that minor fit adjustments are part of the custom process and do not qualify as a refund.
Shipping & Address Responsibility Acknowledgment*

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.
Custom Product Acknowledgment*

I understand that this is a custom-made product created specifically for me and cannot be canceled, refunded, or reversed once production begins.
No Changes After Submission Acknowledgment*

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.
Charge Authorization Language*

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 DamagesI understand that this is a custom order. If I cancel after placing this order, I agree to a $200 cancellation fee to cover materials, labor, and processing. I authorize EASE to charge this fee to my saved payment method through our secure payment processor if I cancel or fail to complete required steps.

$200.00 Quantity

Total

$0.00

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

Final Acknowledgment*

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*

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

ACKNOWLEDGMENTS