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

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

    1395 Curve Crest Blvd. W Stillwater, MN 55082 230 S. Washington St. Suite #1 St. Croix Falls, WI 54024

  • PROFESSIONAL GRADE PROTECTION

    We are proud to partner with TRUFIT (Shark Tank/NFL/NHL) to offer you the same level of protection as your favorite profressional athlete!

  • Does you ave any orthodontic appliances in?*
  • Please select which option you would prefer (fees include in-office 3D custom scans):*
  • Date of Birth*
     / /
  • Format: (000) 000-0000.
  • Are you or your child currently a patient of, or have they already received an orthodontic screening from Orchin + Orchin Specialists in Orthodontics?*

  • We offer complimentary orthodontic screening for children and adults and specialize in precision "tweaks" or smile makeovers.

  • 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?*

  • ATHLETE DENTAL HISTORY

  • Do you have any crowns or large fillings?*
  • Do you have any chipped, broken, or damaged teeth or fillings?*
  • Do you have any loose baby teeth?*

  • ATHLETE MEDICAL HISTORY

  • Allergy to latex/metals?*
  • Allergy to plastics?*
  • Abnormal bleeding?*
  • Asthma?*
  • Congenital heart defect?*
  • Diabetes?*
  • Epilepsy/Seizures?*
  • Heart murmur?*
  • Hepatitis?*
  • HIV+/AIDS?*
  • Rheumatic/Scarlet Fever?*
  • Tuberculosis?*
  • Any other medical conditions?*

  • 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 mouthguard while participating in any of these sports or activities. 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 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. Mouthguards 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 athlete.

  • Date*
     / /

  • Congratulations on choosing to protect your teeth with a TRUFIT mouthguard!  We will reach out to schedule your visit soon, or you may call/text/email us via the information on our site!

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