Grant Application

  • Please apply only once, as multiple submissions may disqualify all applications submitted.
  • Your privacy is important to us. All information will be kept confidentially. Read our Privacy Policy.

Thank you for interest in the Cosmetic dentistry Grants Program. Let’s determine your eligibility! Please start by providing your contact information below:

Name & Contact

Address Information

Hi NAME. nice to meet you. Please let us know where you currently live so we can match you with a participating cosmetic dentist near you.

Employment Information

Great, thanks. Let’s review your current work information:

Your Dental History

OK, thanks. Now let’s get some background on your past dental care:

Your Dental Procedure

OK, we’re almost done! Please indicate which dental procedures you are most interested in.

Please select one or more of the procedures listed below. If you’re not sure which may be the right one for you or are seeking a recommendation, you may skip it.

Please provide any additional information we should know, including if your treatment plan is in advance of a special occasion or any other special circumstances.

Agree & Apply

I agree to the terms and conditions.

Thank You, NAME

Your application has been received and will be processed shortly. One of our representatives will be contact you by email or phone within 2 business days.

Reminder: Please do not submit another application as multiple submissions may disqualify all applications submitted.