Occlusal Guard Consent Form

Occlusal Guard Consent Form
Please review and complete this form to acknowledge your understanding and consent regarding the fabrication and use of your occlusal guard.
Full Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Have you previously used an occlusal guard?
What is the primary reason for your occlusal guard prescription?
Please list any allergies to dental materials or latex.
Do you have any concerns or questions about wearing an occlusal guard?
Should be Empty: