Tooth BLING Intake Estimate Form

First & Last Name

Your Email

Mobile Phone Number

Mailing Address

Date of Birth

Are you over 18 yrs of age? (Please note that anyone under 18 MUST have signed parental consent to get tooth bling.)
yesno
Do you currently or have you ever been diagnosed with any of the following medical conditions?
DiabetesHigh Blood PressureBlood Clotting DisorderHepatitisHIVDental AnxietyNone of the Above
Please list any current medications you are taking:
please include ANY medications, vitamins, or supplements you take daily or regularly!
Do you have any allergies I should know about?
LatexSulfaEggsMetalsOther
If you selected "Other" above, please specify below:

What is the name and phone number for your current general dentist?
-- Don't have one? Just skip to the next question.
When was your last dental cleaning? (Please note that if your hygiene is poor it may affect the adhesion of your tooth bling and you may be asked to get a cleaning done prior to any tooth bling services.)

Please check if you have ever had any of the following procedures done on or for any of the teeth you are hoping to get blinged:
Composite FillingsCrownsImplantsOrthodontic TreatmentDenture(s)None of the Above
Please upload a photo of the teeth you would like blinged with your back teeth biting together (as if you were trying to chew steak!): See below for example.


Please upload a photo of the teeth you would like blinged with your front teeth biting down edge-to-edge (as if you were trying to nibble the edge off a marshmallow): See below for example.


Do you have any ideas or thoughts on what type of bling you'd like to get done?

If you have any inspiration photos of your tooth gem design idea feel free to include that here!

(If any files are too large to be uploaded to this form, please feel free to email them separately to ragingrootsstudio@gmail.com)