Commerce Park Children's Dentistry & Orthodontics
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Mouthguard Registration Form

If you do not wish to submit this form online, you can download a printable form (requires Adobe Acrobat®) and mail to:
Commerce Park Children's Dentistry & Orthodontics, LLC
4702 Main Street
Bridgeport, CT 06606

Patient's Last Name
Patient's First Name
Sex
Parent's Last Name
Parent's First Name
Address
Phone #
Are you currently a patient of Commerce Park Children's Dentistry & Orthodontics? Yes
No
E-mail Address
Sports Played
   
Health Information:  
Is there anything that should be known about your child's health? Yes
No
(If yes, please explain below)
Any history of bleeding problems, HIV/AIDS or heart problems? Yes
No
Does your child have any loose teeth today? Yes
No
Does your child gag easily? Yes
No
Do you need a strap? Yes
No

If you submit this form online, you will have a preprinted form ready for your signature and payment information at the time of your appointment.
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