Mouthguard-Release-Waiver

How did you hear about our custom mouth guards?

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 the sports participant wear a mouthguard in certain sports or activities. As part of a community outreach program to encourage participants to understand the benefits of wearing a mouthguard, White Orthodontics is providing a custom mouthguard and recommending its use in sports-related activities where a mouthguard is advised or required. The wearing of a mouthguard 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 White Orthodontics from all liability of any kind resulting from sporting injuries including aspiration, and/or the providing of the mouthguard, and waive all claims related thereto.

Mouthguard User Name*

Parent/ Guardian Printed Name*

Parent/ Guardian Signature*

Cell Phone Number (we text when mouthguard is ready for pickup!)*

Please enter a valid phone number.

Date*

Date

School name*

Custom mouthguards and case provided at-cost for $35 (free at annual Mouthguard Clinic event on June 7, 2025)

Mouthguard Release and Waiver