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.

Smiles!

Michelle Diskic, RDH.

Name of Person receiving the mouth guard *
Your answer
Parents or Guardians Name ( If under the age of 18 years of age) *
Your answer
Address including Postal Code *
Your answer
Home Phone Number
Your answer
Cell Phone Number *
Your answer
Email Address *
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
Your answer
School Name or Association *
Your answer
Date of Birth *
Your answer
Dentists Name *
Your answer
Physicians Name *
Your answer
Medical History
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 *
Your answer
Are you planning to have orthodontic treatment in the near future? *
Your answer
Color Choice for your new mouth guard? *
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.
Your answer
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