PMG CLUB ORDER FORM

PMG CLUB ORDER FORM

PMG CLUB ORDER FORM

CHOOSE YOUR PIECES
Agree
Full Name On Subscription*

First NameLast Name
Email Address listed on order*
example@example.com
Please review this form carefully before submitting.

All PMG Club selections are limited to the options listed in this order confirmation form. Due to the nature of our subscription pricing, only the styles, metals, and features shown here are included in PMG Club.

If a style, feature, or customization does not appear on this form, it is not available as part of the PMG Club and cannot be added later. Submissions requesting items outside of this form will not be fulfilled.
Top RowBottom Row
Shipment 1Shipment 2Shipment 3Shipment 4
YesNo
YesNo
If your shipping address changed since last shipment, please enter it here.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Hey! Quick heads up so everything goes smoothly.

Inside PMG Club, there are specific styles that are included each month. The options listed below are the styles available for this month’s selection.

If you’d like something outside of these styles, that would be considered a custom order and wouldn’t fall under PMG Club.

To complete your submission:

Select one of the styles listed below.

Choose which teeth you want that style placed on.

Submissions that include styles outside of the listed options won’t be approved, so just make sure you’re choosing from the styles provided.

Thanks!

Your payment method will not be charged unless a cancellation is made. In the event of a cancellation, you authorize EASE to apply any approved fees in line with our Terms & Conditions.*

2 - Tooth Basic PMG Product Image

2 - Tooth Basic PMG

I 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 SizeTop or Bottom

3 - Tooth Basic PMG Product Image

3 - Tooth Basic PMG

I 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 ColorTop or Bottom

Star Cut Out PMG (Cut Out Design is customizable) Product Image

Star Cut Out PMG (Cut Out Design is customizable)

I 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 ColorTop or Bottom

Single Star Cut Out Cap (Cut Out Design is customizable) Product Image

Single Star Cut Out Cap (Cut Out Design is customizable)

I 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 ColorTop or Bottom

3-Tooth Diamond Cut PMG Product Image

3-Tooth Diamond Cut PMG

I 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 ColorTop or Bottom

Heart Cut Out PMG (Cut Out Design is customizable) Product Image

Heart Cut Out PMG (Cut Out Design is customizable)

I 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 ColorTop or Bottom

Semi Bar PMG Product Image

Semi Bar PMG

I 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 ColorTop or Bottom

4-Tooth Heart Cut Out PMG (Cut Out Design is customizable) Product Image

4-Tooth Heart Cut Out PMG (Cut Out Design is customizable)

I 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 ColorTop or Bottom

Surprise Me! Product Image

Surprise Me!

I 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

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

R8R7R6R5R4R3R2R1L1L2L3L4L5L6L7L8EASE STAFF CHOOSESNO TOP ROW
R8R7R6R5R4R3R2R1L1L2L3L4L5L6L7L8EASE STAFF CHOOSESNO BOTTOM ROW
Please list which teeth you are covering and its design. EXAMPLE: L2 - HEART CUT OUT L3 - OPEN *
EXAMPLE: L2 - HEART L3 - OPEN
Please upload a picture of your requested cut out design if you have a piece that includes a cut out design. Please only include a cut out design reference.

Cancelof
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
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 authorize EASE to charge my selected form of payment for this order and any approved change fees in accordance with the Terms & Conditions.
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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