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Grillz
Let us do this part
Today's Date:
Thu Oct 8 2026 02:46
Grillz by Luxurious Enamel
Please read and answer
Y
N
Do you have any allergies? If YES, please explain.

Details: 
List the selected material: 10K gold, 14K gold, silver, gold plated, CZ, moissanite, etc. Client confirms they disclosed any metal allergies.
Y
N
Client confirms they do not currently have braces, loose teeth, dental pain, gum disease, open sores, recent dental work, or untreated cavities.
Y
N
Client gives permission for an oral impression/scan to be taken for the purpose of making custom removable grillz.
Y
N
Client agrees to remove grillz before eating, sleeping, brushing, flossing, or playing sports. Grillz should be cleaned daily and stored in a clean case. Food and bacteria trapped under grillz can increase the risk of tooth decay and gum disease.
Y
N
Client understands grillz may cause irritation, allergic reaction, plaque buildup, bad breath, cavities, gum issues, or discomfort if worn incorrectly or not cleaned properly. The ADA notes that long-term grill wear has not been proven safe, and base metals may cause irritation or allergic reactions.
Y
N
Client understands grillz should fit comfortably. If they feel too tight, loose, painful, or cause irritation, client agrees to stop wearing them and contact the business.
I understand that all grillz are custom-made specifically for my teeth. Once my impression is approved and production begins, all sales are final. No refunds, returns, exchanges, or cancellations will be accepted.
Y
N
I authorize Luxurious Enamel to capture and use your pictures for promotional purposes
Y
N
By signing below, I agree that I have read and fully understand this agreement & all information detailed above. I understand the procedure & accept the risks. I agree & will assume the risk and full responsibility for any injuries, losses, side effects, or damages that might occur to me while I’m performing the procedure. I do not hold the technician responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed by myself today.
If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.
Client Information
I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this agreement.
Name:*
Date of birth:*
 
If you are under 16 your parent/guardian will be required
Age: 
Phone #:*
Email:*
Social Handle:
If you don't mind us tagging you in photos online
Signature:*