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 confidential. Read our Privacy Policy.

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

Name & Contact

First Name *

Last Name *

Email *

Phone Number *

Next: Address

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.

Street Address *

Town / City *

State *

Zip Code *

Next: Employment

Employment Information

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

Are you employed? *

What is your occupation? *

Work Phone Number *

Work Phone Extension

Work Zip Code *

Next: Dental History

Your Dental History

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

Do you have a Regular Dentist?

How long have you been dssatisifed with your Teeth? *

What is your age range? *

When was your Last visit to the dentist? *

Do you have dental insurance?

Other insurance (please specify) *

Next: Procedures

Your Dental Procedure

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

Agree & Apply

I agree to the terms and conditions.

Submit

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.