Tooth Gem Request Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Social media handle *optional*
What are you looking to get? i.e: 2 round gems, butterfly, full tooth, etc...
*
*Optional* Upload any inspo pics (very helpful if you're looking for colored gems so I can check if I have specific colors in stock)
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of
*18K Gold ONLY* Pls list which gem you're looking to get and what color ("18K Gold" Instagram highlight [white or gold])
*18K Gold ONLY* I understand that 18K gem appts must be made 2 weeks in advance (it takes 2-3 weeks for gold gems to arrive)
Yes
No
I understand that gems can only be applied to real & healthy teeth (no veneers, crowns, fillings, braces, or fake teeth)
*
Yes
No
I understand that I cannot remove these gems on my own and must get them removed professionally & I understand the risk and damage if I try to remove them myself
*
Yes
No
I understand tooth gems are semi-permanent and can last anywhere from a month to 2+ years following proper aftercare
*
Yes
No
I understand I must be 18+ to receive tooth gems & must upload a valid form of ID showing my DOB
*
Yes
No
Upload valid drivers license or ID
*
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Drag and drop files here
Choose a file
Cancel
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I understand that starting price for Swarovski round crystals are $60 and 18K Gold Gems & Designs start at $100
*
Yes
No
I understand that by submitting this form does not guarantee an appt. All appt requests are subject to review and approval by Studio Kat V. Upon approval, Studio Kat V will contact me to set-up an appt time
*
Yes
No
Once my request has been approved, I understand a $30 NONREFUNDABLE deposit is required to secure my appt time
*
Yes
No
I have read the "Tooth Gem Policy" highlight located on Instagram & understand my appt will be canceled if it has not been read
*
Yes
No
Signature
*
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Should be Empty: