Sports Mouthguard ORDER FORM
The National Health and Medical Research Council’s research into Head and Neck Injuries in Football (1996) recommended players of all contact sport including rugby, soccer and basketball, should wear a mouth guard. The Dental Profession and the Australian Dental Association strongly recommend professionally constructed mouthguards for their superior fit, protection and comfort than boil and bite types. Mobile Dental Services have been booked to make custom mouthguards for the boys. Their mobile clinic will be at the School on the afternoon of Wednesday 10th February and Friday 12th February for impressions. Boys will be notified of their allocated time by their Boarding Co-Ordinator. Mouthguards will be delivered to School by Monday 22nd February, and the mobile clinic will return on Wednesday 24th, should any of the boys require their mouthguard to be adjusted, or missed their initial impressions. After this visit, all adjustments can be carried out at Bupa Dental Hunters Hill, located 300m from Joeys # 1 Oval. The cost of this service is $180. The mouthguard comes with name and mobile number embedded on the inside of the guard plus a protective case. Generous Health Fund rebates apply – 100% back for Bupa Health Fund Members. Mouthguard Order Forms will need to be received prior to Tuesday 9th February, accompanied by cheque or credit card details for $180 in favour of Mobile Dental Services. You will receive a receipt upon full payment to claim your private health rebate, either online or in person with your Health Fund. Should you have any queries - please dont hesitate to contact Mobile Dental Services on 1800 637 637.
Student Name
*
First Name
Last Name
Student Year
*
Parent Name
*
Parent Phone
*
-
Area Code
Phone Number
Student Name and Phone Number
*
Please print EXACTLY what you wish to appear on the mouthguard
Please select your Colour Preference
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Cerise / Blue
$
180
AUD
Blue
$
180
AUD
Clear
$
180
AUD
White
$
180
AUD
Black
$
180
AUD
Black/White
$
180
AUD
Fluro Pink
$
180
AUD
Fluro Green
$
180
AUD
Fluro Orange
$
180
AUD
Custom Colour
Additional week required : please be sure to also note your preference below
$
200
AUD
If you selected Custom Colour: note your preference
REUIRED FOR CUSTOM MOUTHGUARDS ONLY ($200 option)
Payment by:
*
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Visa / Mastercard
Amex
Card Number
*
Name on Card
*
Card Expiry
*
mm/yy
I authorise payment and give consent for a dental impression
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