Sports Mouthguard Intake Form
Please complete this form to help us fit and prepare your custom sports mouthguard. All information is confidential and used solely for your mouthguard fitting.
Athlete Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Sport Played
*
Please Select
Football
Basketball
Hockey
Rugby
Wrestling
Martial Arts
Soccer
Lacrosse
Other
Level of Play
*
Youth (under 13)
Teen (13-17)
Adult (18+)
Professional/Elite
Preferred Mouthguard Type
*
Custom-fitted
Boil-and-bite
Stock
No preference
Preferred Mouthguard Size
Youth/Small
Medium
Large
Custom size
Not sure
Do you currently use braces or other dental appliances?
*
Yes, braces
Yes, other dental appliances
No
Do you have any dental or jaw concerns (e.g., missing teeth, jaw pain, TMJ)?
Missing teeth
Jaw pain
TMJ disorder
Sensitive gums
None
Other
Have you used a mouthguard before?
*
Yes, regularly
Yes, occasionally
No
If you have used a mouthguard before, please describe any fit or comfort issues experienced.
Additional Notes or Special Instructions
Submit Intake
Should be Empty: