Appointment Request Form
To request an appointment, please fill out the information below.
Please note*
Bookings for the following dates will be held in different locations: October 10th will be at the City Foundry in St. Louis. October 17th downtown Cape Girardeau at the Muddy River Makers Market. October 24th at the Thrift Shop in Carbondale, IL.
When works best for you?
*
Contact Information
Name
*
First Name
Last Name
Preferred Pronouns
Please Select
She/Her
He/Him
They/Them
It/Its
He/She/They
She/They
He/They
Any
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
How did you hear about me?
SEEING THE VISION
If you’re working on a budget, how much are you comfortable spending?
$30-$60
$70-$100
$110-$150
$160-$200
$200+
Flexible
Please provide any inspo photos for your dream look:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Request 18k Gold Catalog
Yes
No
Are you wanting to apply gems to your retainer (Invisalign)?
Yes
No
DENTAL CARE
Have you had your teeth cleaned professionally in the last 6mo?
Yes
No
Please give a brief description on your dental history
What does your at home oral care look like?
Please provide any products used
Request dentist referral
Yes
No
PREP FOR GEMS
I understand I should have my teeth professionally cleaned at least 6 months before my tooth gem appointment. Failure to have professional cleanings can lead to cavities and inability to properly adhere gems, making them fall off earlier than expected.
*
Yes
No
I understand, I cannot eat or drink anything that’s not a clear liquid for two hours after my appointment. It is advisable to eat, brush, and floss prior to your appointment.
*
Yes
No
I understand tooth gem removal MUST be performed by a dental professional. Removal done by anyone other than a dental professional can cause irreversible damage to the tooth.
*
Yes
No
I understand, I must be 18 years or older to get tooth gems.
Yes
No
I understand, if I am under the age of 18 years old, I must have a legal guardian sign for me. A birth certificate or other legal documentation that states my legal guardian is signing for me, may be required.
Yes
No
Signature
*
Continue
Continue
Should be Empty: