Mouthguard Registration – DE Mouthguards

1Wearer Info

2Dental / Medical Info

3Mouthguard Selection

4Finalise Order

Is this mouthguard for a child?(Required)

Yes

Wearer Name(Required)

First Last

Preferred Name

Wearer Date of Birth(Required)

Please note the DOB entry is in US format MONTH/DAY/YEAR

MM slash DD slash YYYY

HE BookingID

This field is hidden when viewing the form

Deal Name

This field is hidden when viewing the form

Club Name

Your sporting club name?

Parent Name(Required)

First Last

Mobile Number(Required)

Email(Required)

Enter Email Confirm Email

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mailing Address(Required)

Same as previous

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Does your child have an allergic reaction to latex?(Required)

Yes

Please list any other allergies

Does your child have a regular dentist?(Required)

Yes

Is your child undergoing or about to commence Orthodontic treatment?(Required)

Yes

Estimated date of commenting treatment(Required)

MM slash DD slash YYYY

Please review the list below and check any that apply to your child:

Strong Gag Reflex

Small Mouth / Palate

Missing or Wobbly Teeth

Dental Phobia

Previous difficulty taking an impression

Is there anything we should know about your childs medical or dental history?

Note:

The team from DE Mouthguards may contact you to discuss your appointment based on your responses

DE Custom Mouthguard

Price:

Private Health(Required)

Yes

Health Fund(Required)

If you have extra's health insurance,please ensure you bring your physical or digital Private Health Insurance card with you to your appointment to make your claim. We are unable to complete claims with just the numbers or a photo, we will need the physical or digital card on the day.

Please list other Health Fund

Member Number(Required)

Number/Series on insurance card(Required)

Please Note - this is the number next to the mouthguard wearer name on your health insurance card

Please enter a number from 1 to 9.

Item Codes charge to health fund will be a 013 (limited oral exam) & 151 (mouthguard)

Do you require a dual layer mouthguard?(Required)

Dual layer mouthguards are recommended for all Adults, pre-teen & teenage children that are involved in high-impact sports. The main difference between a single and dual layer mouthguard is the thickness and level of protection. Dual-layer mouthguards have a 2nd inner layer that offer increased shock absorption compared to single-layer mouthguard.

Yes

Do you require the "Name" & "Mobile Number" to be included on the mouthguard?(Required)

Yes

Name on mouthguard(Required)

Mobile Number on mouthguard(Required)

Colour Choice(Required)

Single colour, your team colour and our list of selected sporting teams as listed are our only available colour options.

Single Colour

My Club Colours

AFL Team

WAFL Team

Other Teams

AFL Team(Required)

West Coast Eagles

Fremantle Dockers

Adelaide Crows

Brisbane Lions

Carlton

Colligwood

Essendon

Geelong

Gold Coast Suns

GWS Giants

Hawthorn

Melbourne

North Melbourne

Port Adelaide

Richmond

St Kilda

Sydney Swans

Western Bulldogs

WAFL Team(Required)

Claremont

East Fremantle

East Perth

Peel Thunder

Perth

South Fremantle

Subiaco

Swan Districts

West Perth

West Coast Eagles

Other Team(Required)

Australia (Green & Gold)

Perth Wildcats

Perth Lynx

Perth Glory

West Coast Fever

Indigenous (Black Yellow Red)

Single Colour(Required)

Please select a single colour for your mouthguard. Click here to view the full set of colours.

01 Black

02 Dark Blue

03 Maroon

04 Silver

05 Gold

06 Royal Blue

07 Lilac

08 Sky Blue

09 Green

10 Pink

11 Red

12 Turquoise

13 White

14 Yellow

15 Fluro Orange

16 Fluro Yellow

17 Fluro Green

18 Clear

19 Fluro Pink

20 Rac Green

21 Brown

22 Fluro Red

23 Apple

24 Lavender

25 Cerise

26 Sandstone

27 Cherry

28 Amethyst

29 Teal

30 Aussie Yellow

31 Metallic Mist

32 Shrimp

33 Metallic Green

34 Cornflour Blue

35 Leaf Green Bio

36 Solid Orange

Total

Shipping

No (pickup from club)

Yes (Australia Post Registered & Signed)

Practice Booking Shipping

No (Pickup from Practice)

Yes (Australia Post Registered & Signed)

Credit Card

Card Details

Cardholder Name

Total

Name

This field is for validation purposes and should be left unchanged.

Mandatory Mouthguard Registration

Contact Info