I, blanks (name) am the blank (parent/legal guardian) of the above mentioned child and have the authority to give consent to treatment on behalf of said child. I acknowledge and consent that the Clinical Professionals of Aldershot Dental Hygiene are not providing any dental examination for my child. I am aware that a mouth-guard is a piece of hard plastic which is designed to fit over and cover the upper teeth to help protect the child's teeth and attempt to reduce the risk of dental injuries and trauma (concussions) during athletic activity and that the mouth-guards can break down from usual use by the child and that mouth-guard pieces can be swallowed or inhaled if broken. I understand that the mouth-guard should be checked regularly to ensure its not broken and that if it is, the child will no longer use the mouth-guard. I acknowledge that: My child is attending the office only for the purpose of having a custom mouth-guard made (which shall include the taking of impressions of the upper teeth and fitting the mouth-guard) and I hereby consent to this service being provided to my child by the Clinical Professionals of Aldershot Dental Hygiene. I also acknowledge that Aldershot Dental Hygiene is not responsible for any injury or damages sustained by the child while using a mouth-guard. I hereby release Aldershot Dental Hygiene from any and all liability arising from the use of the mouth-guard by the child or relating thereto in any manner whatsoever. I give permission for Aldershot Dental Hygiene to use any photographs taken for promotional purposes including but not limited to: copyright purposes, illustration, advertising, legal use and website content.
Aldershot Dental Hygiene
384 Plains Rd East, Burlington, ON L7T0A4
Phone:(289) 427-0220 Fax:(289) 427-0219