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?
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YES
NO
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.
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AGREE
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.
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First Name
Last Name
ORDER NUMBER - 4 DIGITS ONLY
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Email address on order
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example@example.com
Which TOP teeth do you want to cover?
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TOP - R8
TOP - R7
TOP - R6
TOP - R5
TOP - R4
TOP - R3
TOP - R2
TOP - R1
TOP - L1
TOP - L2
TOP - L3
TOP - L4
TOP - L5
TOP - L6
TOP - L7
TOP - L8
NOTHING ON TOP
Which BOTTOM teeth do you want to cover?
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BOTTOM - R8
BOTTOM - R7
BOTTOM - R6
BOTTOM - R5
BOTTOM - R4
BOTTOM - R3
BOTTOM - R2
BOTTOM - R1
BOTTOM - L1
BOTTOM - L2
BOTTOM - L3
BOTTOM - L4
BOTTOM - L5
BOTTOM - L6
BOTTOM - L7
BOTTOM - L8
NOTHING ON BOTTOM
WHAT COLOR IS YOUR PIECE GOING TO BE?
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Please Select
NATURAL SILVER
GOLD PLATING
ROSE GOLD PLATING
GOLD - 10KT & UP ONLY
WHITE GOLD - 10KT & UP ONLY
ROSE GOLD - 10KT & UP ONLY
METALLIC E- COATING
RHODIUM
WHAT BASE METAL DID YOU BUY?
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Please Select
SILVER925 BASE
10KT GOLD
14KT GOLD
18KT GOLD
22KT GOLD
24KT GOLD
TOOTH SELECTION
HERE IS AN EXAMPLE BELOW OF WHAT THE FORM SHOULD LOOK LIKE THAT YOU ARE UPLOADING INTO THE NEXT BOX.
If you skipped the above step, go back up and complete it. Upload the completed form (example above) that includes your order details. It is not a screenshot of your order or order confirmation
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Browse Files
Drag and drop files here
Choose a file
Cancel
of
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. THIS IS VERY IMPORTANT IF YOU WANT SOMETHING SPECIFIC.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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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Browse Files
Drag and drop files here
Choose a file
Cancel
of
Do you have a chipped or missing tooth that you're attempting to cover with your Protective Mouth Grill?
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YES
NO
ACKNOWLEDGMENTS
You're almost done, but we need to know you acknowledge and understand the terms!
Dental Impression Responsibility Acknowledgment
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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.
Production Timeline & Delay Acknowledgment
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I understand that production timelines are estimates, not guarantees, and may be extended due to customization, materials, or required corrections.
Fit & Adjustment Acknowledgment
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I understand that minor fit adjustments are part of the custom process and do not qualify as a refund.
Custom Product Acknowledgment
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I understand that this is a custom-made product created specifically for me and cannot be canceled, refunded, or reversed once production begins.
No Changes After Submission Acknowledgment
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I understand that once my order is submitted, no changes are guaranteed, and any approved changes require a separate Order Change Request Form and applicable fees.
Shipping & Address Responsibility Acknowledgment
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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.
Final Acknowledgment
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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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