Command Mouthguards - Prebooking Form

Command Mouthguards Consent Form

Albert 88 Pty Limited trading as Command Mouthguards ABN 84 645 229 581
Name of Patient/Player:

First NameLast Name
Sex
DOB

DayMonthYear
Date
Which Club Fitting Day will you be attending?*
Name of Parent/Guardian (if applicable):

First NameLast Name
Address

Street Address

Street Address Line 2

SuburbState

Postcode
Phone Number
Email
example@example.com
Dental History
Is the patient/player undergoing any dental treatment at this time?

YesNo
If yes, please provide details:

Command Mouthguards Consent Form

Albert 88 Pty Limited trading as Command Mouthguards ABN 84 645 229 581
Please CAREFULLY READ the following BEFORE SIGNING at the end. If you are unable to sign for any reason, then please speak with the Command Mouthguard representative.

By completing the details requested above and signing this form:

I consent to Command Mouthguards fabricating a custom fitted mouthguard for the Player named above for the agreed fee. As part of this process, an intraoral 3D scanner will be used to create a digital impression of the Player’s mouth; and

I confirm that I have read and agree with the following:
- This consultation is for a mouthguard fabrication only (Procedure) and a mandatory full dental examination must be carried out on the Player by my/ their preferred dentist every 6 months. Command Mouthguards is not responsible nor liable for any actual or possible contraindications to the mouthguard fabrication which may include the presence of tooth decay, infection, plaque and/or calculus build up, gum/periodontal disease, loose teeth, oral appliances (i.e. orthodontic appliances).
- If any conditions that may contraindicate the fabrication of a custom mouthguard are noted during the consultation, I understand that these conditions must be treated by a dentist of my choosing prior to the Procedure by Command Mouthguards.
- I understand that the correct use of a custom mouthguard can act as a protective aid to help decrease the incidence and severity of dental and brain injuries. However, I agree that no assurance or representation is or has been made or given to me by Command Mouthguards that the use of a custom fitted mouthguard will prevent such injuries from occurring.
- During this consultation or at any time prior to the Procedure, I have the opportunity to ask questions, discuss issues or raise concerns which will be addressed before the Procedure. Any further information provided, whether verbal or written, and irrespective of the means by which information, instructions or other material is provided to me (in hardcopy, electronic or references where such material can be accessed), will be reviewed and/or considered and/or followed by me (as appropriate).
- All pertinent information, including medical history, conditions or current treatments relating the Player which may be of relevance to the Procedure has been or will be disclosed to Command Mouthguard prior to the Procedure.
- Command Mouthguard may produce, use, reproduce or communicate (in hardcopy or electronic format) any photographs, images or recordings of the Procedure or its results, for the purposes of Command Mouthguard publications or promotional activities, including via its websites, social media sites , promotional or marketing materials, provided that the use of photographs, images or recordings are not adverse or defamatory, and all photographs, images or recordings remain the property of Command Mouthguards.
- If I am signing this consent as Guardian, I am entitled or authorised to act in that capacity.
Player/ Parent/Guardian Signature:*

Clear
Player/Parent/Guardian Name*

First NameLast Name
Date Signed*

DayMonthYear
Date

Command Mouthguards Consent Form

Albert 88 Pty Limited trading as Command Mouthguards ABN 84 645 229 581
Payment and Health Fund Claims
To complete the order process, please select your preferred payment option*

Health Fund Claim and Pay in Person: At the time of scanning, patients/parents present their private health fund card to claim ‘on the spot’ (Digital Wallet or physical cards for all Australian health funds are accepted) and use a debit/credit card (Visa + Mastercard – digital or physical) to complete any ‘gap’ payments (if necessary).No Health Fund Claim Necessary – In Person: At the time of scanning, patients/parents present a debit/credit card (Visa + Mastercard – digital or physical).
Name on Mouthguard:
This is a small label on the inside of the guard
Phone Number on Mouthguard:
Colours and Designs

Mouthguard colours and designs can be chosen by the patient at the time of scanning
Should be Empty:

Command Mouthguards Consent Form

Dental History

Command Mouthguards Consent Form

Command Mouthguards Consent Form

Payment and Health Fund Claims

Colours and Designs