Pro Tec Custom Mouth Guard Website Order
Pro Tec Custom Mouth Guards
The information below is being collected to ensure the safe and effective delivery of a custom mouth guard.
Michelle Diskic, RDH.
Name of Person receiving the mouth guard
Parents or Guardians Name ( If under the age of 18 years of age)
Address including Postal Code
Home Phone Number
Cell Phone Number
Your email address will only be used to advise you of future clinics we hold and will not be shared with other companies or organizations
School Name or Association
Date of Birth
Pro Tec custom mouth guards follows all standards set out by the College of Dental Hygienists of Ontario. Pro Tec works within the accordance of the privacy act pertaining to the collection of personal information.
Do you currently have any health issues or allergies
Are you planning to have orthodontic treatment in the near future?
Color Choice for your new mouth guard?
Orange / White
Orange / Black
Red / Yellow
Black / Orange
Blue / White
Green / Blue
Yellow / Black
Purple / White
Red / White / Green
Red / White / Blue
Red / White / Black
Red / White / Red
Yellow / Red / Yellow
Pink Cancer Survivor
I hereby give my consent for myself/my child to have an impression and a custom mouth guard made and will assume the fees associated with these procedures and agree to pay the $50 (HST included) fee.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service