LET'S CONFIRM 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?
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
Email address on order
example@example.com
Which TOP teeth do you want to cover?
Which BOTTOM teeth do you want to cover?
WHAT COLOR IS YOUR PIECE GOING TO BE?
WHAT BASE METAL DID YOU BUY?
TOOTH SELECTION
Click here to select teeth and tooth designs.

This is how we know what to put on each tooth.

Once you've selected teeth, download the JPEG and upload it below.
Upload the JPEG that includes your order details.

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List any design details we should know
EX: R2 - HEART CUT OUT R3 - FLOATING "H" WITH SCRIPT FONT.
UPLOAD ANY INSPO PHOTOS YOU MAY HAVE

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

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Do you have a chipped or missing tooth that you're attempting to cover with your Protective Mouth Grill?
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
Custom Product Acknowledgment
No Changes After Submission Acknowledgment
Shipping & Address Responsibility Acknowledgment
Final Acknowledgment

In the event of a cancellation or chargeback, I authorize EASE to charge my selected form of payment for this order and any approved change fees in accordance with the Terms & Conditions.

CHARGEBACK PREVENTATIVE

THIS IS JUST AN AUTHORIZATION. WE ARE NOT CHARGING YOU.

$200.00 Quantity

Total

Payment Methods
Credit Card Number	Security Code
Expiration Month	Expiration Year

Signature of client.
Should be Empty:

LET'S CONFIRM YOUR ORDER

TOOTH SELECTION

ACKNOWLEDGMENTS

In the event of a cancellation or chargeback, I authorize EASE to charge my selected form of payment for this order and any approved change fees in accordance with the Terms & Conditions.*

In the event of a cancellation or chargeback, I authorize EASE to charge my selected form of payment for this order and any approved change fees in accordance with the Terms & Conditions.