Tooth Gems Request Form

Tooth Gems Request Form

~Catharsis Tooth Gems~
Thank you for your interest in booking with Amy J. for Tooth Gems! To ensure a smooth and efficient process, please fill out the form below with proper information and which tooth/teeth you would like to be modified.

If you would prefer a walk-in consultation, Amy is available Saturdays only from 12:30 PM to 5:00pm, we may expand availability as demand grows.

Our service for Tooth Gems is a $50 minimum, $40 which includes set up and application process. Each crystal is $10, prices may vary depending on the type of crystal you choose.

Additional booking details will be provided after we have reviewed your submission.

We look forward to bringing a sparkle to your smile!
By using our form, you acknowledge and accept that you may be contacted via email/text message regarding your services by Catharsis Tooth Gems. Your continued use of our services implies your consent to this policy. Please be assured that we respect your privacy, and your contact information will not be shared with third parties for marketing purposes. Standard message and data rates may apply for text messages.

I Accept
Have You Been To Our Shop Before?

YesNo
Full Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
If You Are A Minor Under 18 You Must Have Parent Consent To Book

We do NOT work with minors under 16 years in age.
Are You A Minor?

YesNo
Full Name Of Consenting Parent

First NameLast Name
Please Upload Consenting Parents ID And Minors Birth certificate

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Tooth Gem Information

Please ensure all fields are completed to provide thorough information. Amy will verify your design ideas during your appointment.
How Many Gems Would You Like?
Base services: $40 Crystals: $10 each ( price may vary by type) $50 minimum
Which Tooth/Teeth Are You Looking To Apply Gems?
E.g. 5, 8, and 21.
Please Upload Any Reference Photos For Gem Layout

Cancelof
Amy Is Currently Booking Saturdays 12:30 p.m.-5:00 p.m.

Please select what timeframes work best with your current schedule. We do NOT book appointments after 5 p.m.
Preferred Time Slot

Anytime12:30 p.m. - 1:00 p.m.1:00 p.m. - 1:30 p.m.2:00 p.m. - 2:30 p.m.2:30 p.m. - 3:00 p.m.3:00 p.m. - 3:30 p.m.3:30 p.m. - 4:00 p.m.4:00 p.m. - 4:30 p.m.4:30 p.m. - 5:00 p.m.
If You Have Any Scheduling Specifics Or Dates Please Let Us Know Here
Please list requested dates here. E.g. MM/DD/YYYY
I understand that my requested date is not guaranteed.

I Understand
By checking the box below and submitting this form, I confirm that the information provided is accurate, and I understand that I will complete a full consent form in person before my appointment.

I Understand
I am aware that my inquiry might require an in-person consultation.

I Understand
We appreciate your time in completing this request form!

Once your form has been reviewed,

we will contact you with further information on booking procedures.

~Thank You~
Should be Empty:

Tooth Gems Request Form

If You Are A Minor Under 18 You Must Have Parent Consent To Book

Tooth Gem Information

Amy Is Currently Booking Saturdays 12:30 p.m.-5:00 p.m.