Orchin Mouthguard Consent

Dr. Jill M. Orchin + Dr. Andrew M. Orchin

1395 Curve Crest Blvd. W Stillwater, MN 55082
No (Great! Please complete this registration form!)*******Yes !!STOP!! (Since custom mouth guards fit so well, they should not be used while actively moving teeth. We recommend Shock Doctor Orthodontic Mouth Guards for your child, and will be happy to see them at the next event when their appliances are removed!)
What color mouth guard would you like?*
Player Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Grade*
School*
Parent/Guardian First/Last name*

First NameLast Name
Home Address*

Home Address

Street Address Line 2

CityState

Zip
Cell Phone*
Format: (000) 000-0000.
Email*
example@example.com
Sport*
Team*
Coach
If unknown, please leave blank.
Family Dentist*
Family Orthodontist
YesNoNot yet but tell me more!
We are proud to offer hockey players and their immediate families a 5% courtesy off of orthodontic treatment!
The American Association of Orthodontists recommends all children receive a screening from an orthodontist by the age of 7. Typically treatment is not indicated at this time, but sometimes we find issues that allow us to help little problems from turning into big ones. We can also typically provide you with knowledge to help you plan for any future orthodontic concerns. We offer this as a complimentary screening for all children (and adults too!) Would you like us to contact you to arrange a screening for you or your child?*

YesNoUncertain at this timeI would like to be contacted to schedule a free screening for myself or another family member
PLAYER DENTAL HISTORY
YesNo
YesNo
YesNo
PLAYER MEDICAL HISTORY

Has your child ever had any of the following problems?
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Yes (please describe below)No
If yes to the above - please describe:
YesNo
The risk of serious injury to the mouth is inherent in virtually any sport or activity that might result in trauma to the head. Therefore, it is important that you or your child wear a mouth guard while participating in any of these sports or activities. The wearing of a mouth guard of any kind cannot prevent injuries from occurring. However, in most cases it may help reduce the degree of severity of injuries.

I have read and understand the above information. By my signature below, I release Orchin + Orchin Specialists in Orthodontics from all liability of any kind resulting from sporting injuries including aspiration, and/or the providing of the mouth guard, and waive all claims related thereto. I realize that though the custom mouth guard is the best protection available, it is only a deterrent tio injury and is no guarantee of injury prevention. Mouth guards are our best defense but are not infallible. I agree that by wearing the mouth guard I am consenting that the fit is comfortable and is not placing pressure on my teeth or causing unusual movement or discomfort to my teeth. I agree to stop wearing the mouthguard immediately if I have any concerns with fit.

I authorize the staff of Orchin + Orchin Specialists in Orthodontics to perform the necessary procedures to fabricate a custom mouth guard for the above named player.
Parent/Guardian Signature*
Parent/Guardian (Printed)*
Date*

MonthDayYear
Date
*AS A COMMUNITY SERVICE, DRS. ORCHIN WILL PROVIDE

ONE MOUTH GUARD PER ATHLETE PER YEAR*
Should be Empty:

Dr. Jill M. Orchin + Dr. Andrew M. Orchin

We are proud to offer hockey players and their immediate families a 5% courtesy off of orthodontic treatment!

PLAYER DENTAL HISTORY

PLAYER MEDICAL HISTORY