Player Information
First Name:
Last Name:
Date of Birth:
Gender:
Male
Female
Grade:
School:
Parent/Guardian's First & Last Name:
Home Address:
City:
State:
Zip:
Home Phone #:
Cell #:
Email:
Sport:
Team:
Coach:
Family Dentist:
Family Orthodontist:
Player Dental History
Do you currently wear braces or an orthodontic appliance?
Yes
No
Do you have any crowns or large fillings?
Yes
No
Do you have any chipped, broken or damaged teeth or fillings?
Yes
No
Do you have any loose baby teeth?
Yes
No
Player Medical History
Allergy to Latex / Metals?
No
Yes
Allergy to Plastics?
No
Yes
Abnormal Bleeding?
No
Yes
Asthma?
No
Yes
Congenital Heart Defect?
No
Yes
Diabetes?
No
Yes
Epilepsy / Seizures?
No
Yes
Heart Murmur?
No
Yes
Hepatitis?
No
Yes
HIV+ / AIDS?
No
Yes
Kidney / Liver Problems?
No
Yes
Rheumatic / Scarlet Fever?
No
Yes
Tuberculosis?
No
Yes
Any other medical conditions?
No
Yes
I authorize the staff of Dr. Trudy Bonvino to perform the necessary procedures to fabricate a custom mouthguard for
(Player's Name).
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 Dr. Trudy Bonvino 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. I realize that though the custom mouthguard is the best protection available, it is only a deterrent to injury and is no guarantee of injury prevention. Mouthguards are our best defense but are not infallible.
Parent/Guardian Signature:
Date:
**As a community Service, Dr. Trudy Bonvino will provide one mouthguard per athlete per year**