Download – Mouthguard Consent

PLAYER INFORMATION
Last Name___________________________________________ First Name_______________________________________________
Date of Birth_________________________ Gender _______ Grade_______ School________________________________________
Parent/Guardian’s First & Last Name ______________________________________________________________________________
Home Address _____________________________________City______________________State_________Zip__________________
Home Phone # ____________________________ Cell # ______________________________ Email ___________________________
Team ___________________________________________ Coach ______________________________________________________
Family Dentist _________________________________________ Physician ______________________________________________
Family Orthodontist ___________________________________________________________________________________________
Is your child a current patient of Dr. Trudy Bonvino? Yes
No
PLAYER DENTAL HISTORY
Y
N
Do you currently wear braces or an orthodontic appliance?
Y
N
Do you have any crowns or large fillings?
Y
N
Do you have any chipped, broken or damaged teeth or fillings?
Y
N
Do you have any loose baby teeth?
PLAYER MEDICAL HISTORY
Has your child ever had any of the following problems?
Y
N
Allergy to Latex / Metals
Y
N
Heart Murmur
Y
N
Allergy to Plastics
Y
N
Hepatitis
Y
N
Abnormal Bleeding
Y
N
HIV+ / AIDS
Y
N
Asthma
Y
N
Kidney / Liver Problems
Y
N
Congenital Heart Defect
Y
N
Rheumatic / Scarlet Fever
Y
N
Diabetes
Y
N
Tuberculosis
Y
N
Epilepsy / Seizures
Y
N
Any other medical condition(s)
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
________________________________________
Parent/Guardian (Printed)
_____________
Date
**As a community service, Dr. Trudy Bonvino will provide one mouthguard per athlete per year**