Kozlowski Orthodontics | Mouthguard Patient Info Form

Please answer the following questions about your child’s history:

Does your child have an allergy to latex?

Y N

Had tonsils/adenoids removed

Y N

Mouth breathing

Y N

Chronic sinus issues

Y N

Speech problems and/or speech therapy

Y N

Thumb or finger sucking

Y N

Snoring

Y N

Clenching or grinding

Y N

Has your child ever received an injury to the face, mouth, teeth, or chin?

Y N

Has your child ever been evaluated or had orthodontic treatment before?

Y N

Are you interested in a brief orthodontic evaluation for your child?

Y N

Have you had a mouth guard made by Kozlowski Orthodontics before?

Y N

Who is your child’s dentist?

What is the sport & league name?

I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidence, and that it is my responsibility to inform this office of any changes in my child’s medical status.

Signature of Parent or Guardian

Date

By completing this form you agree to receive the occasional email from Kozlowski Orthodontics regarding the latest information on promotions and other happenings in the Koz world.

Confidential Patient Information for Mouth Guard Program

Confidential Medical & Dental History

Please answer the following questions about your child’s history: