OneGuard Athletics Performance Optimization MouthGuard Registration, Payment, & Signature Form

OneGuard

Athletics Performance Optimization

MouthGuard Registration, Payment, & Signature Form

Thank you for choosing OneGuard Solutions TM, to optimize your physical performance, and improve your overall wellness. OneGuard provides 4 Oral-Appliance Solutions affecting 75% of the population, and impacting our physical, cognitive performance, our sleep, our rest, our balance, flexibility, strength, and our discomfort. These symptoms impact our daily life and our physical performance in daily activities, athletic abilities, professional cognitive performance, and our leisure with our familes.

Let's discover what is impacting your life and what you may be interested to improve or optimize.

SportGo is indicated for Athletics Performance Optimization $499

SleepGo is indicated for Sleep Apnea/Snoring-Sleep Oxygenation Optimization $1800

NightGo is indicated specific for Sleep, Pain, & Rest Optimization $1800

TMDGo is indicated for Head Posture, Headache, & TMD Treatment Optimization $2400

Bite Deprogrammer in indicated for Acute Face Pain, Jaw Pain, & Headaches Control Optimization $500

Smile ReFyne (TOTAL) indicated for individuals interested in a New Snap-On-Smile for both the top and bottom teeth, a New Bite, New You $3900

Smile ReFyne (TOP) indicated for individuals interested in a New Snap-On-Smile only on the top teeth, a New Bite, New You $1800

Smile ReFyne (BOTTOM) indicated for individuals interested in a New Snap-on-Smile only on the bottom teeth, a New Bite, New You $1800

Bite Deprogrammer is indicated for patient in Acute Face Pain, Jaw Pain, & Headaches Control Optimization- $500

Invisalign (TOTAL) is discrete orthodontics with clear aligners where treatment is performed on both top and bottom arches Invisalign NOT Braces! $6000

Invisalign (ONE ARCH) is discrete orthodontics with clear aligners, where treatment is performed on one top OR bottom arch, Invisalign NOT Braces! $3000 (one arch)

How Does It Work? 4 EASY STEPS

Fill Out This Registration, Signature, & Order Form
Complete an emailed Credit Card Authorization to pay for the OneGuard Solutions Performance Optimization Service (This includes the OneGuard oral appliance & a Doctor-Guided Experience).
Schedule Your Doctor-Guided Visit. We can file insurance claims depending on your plan. If your insurance pays, you will receive insurance reimbursement check sent to your house.
Receive Your Appliance within 2 weeks shipped to your house. You may schedule another Doctor-Guided Experience at that time.

Before you start filling out the form, we will need you to upload the following items which it is easier to have those available and saved on your phone or desktop and upload at time of registration filling out the order form.

Please upload

front back of dental and medical insurance card
picture of your face
picture of your smile close-up
sports team logo or inspiration image
any special images or instructions

Thank You. If you have any questions, please contact the office at (315) 552-1050 or Dr. Dorothy Kassab at dorothykassab@gmail.com

First Name*

Last Name*

Date of Birth*

Phone Number*

Street Address*

State*

Zip Code*

Email Address*

HIPPA & Informed Consent(REQUIRED Read&Check Each)*

Select or enter value

Parent/Guardian First Name

Parent/Guardian Last Name

Parents/Guardian Phone Number

Parent/Guardian Email

Parents Address if Different From Patient

Consent to communicate with Parent/Guardian

What Would You Like To Optimize With The OneGuard?*

Select or enter value

Seeking to improve Performance in*

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Color Choice (up to 3)

Select or enter value

School/Team Name*

Choice of Design (one logo permitted)

Upload below your logo or inspiration image to imbed in the front of the MouthGuard.

Select

Quantity for Multiple of The Same OneGuard Design

Total Cost To Be Charged

Please enter the $ TOTAL COST of all the appliances your are purchasing. We will email you another payment link and authorization form.

Do You Have Dental/Medical Insurance (Upload)

Select

File Upload

Please upload

front back of dental and medical insurance card
pictures of your face
picture of your smile closeup
sports team logo or inspiration image
any special images or instructions

Drag and drop files here or

Insurance to Bill

Select or enter value

Would You like your Doctor Guided Experience "in-Person" or convenient "Tele-Medicine"

After your OneGuard Box comes in to your address, the next step is a Doctor-guided visit for an assessment, answer any questions you may have, and to use the items provided to you to obtain impressions and the optimized bite relationship to fabricate your Performance Optimization OneGuard Oral Appliance of your choice or that is indicated based on your symptoms you are trying to improve.

Select

Medical History have you ever had

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What medications are you taking?

Allergies:

Digital Signature (Patient's Name & Date)*

Send me a copy of my responses

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