Dental Grant Application

Thank you for your interest in the Cosmetic Dentistry Grants Program!

Apply to receive financial assistance for a dental treatment plan with a top-rated cosmetic dentist.
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.

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

The Cosmetic Dentistry Grants (CDG) program does not provide free or fully paid dental procedures. There are always out-of-pocket costs for patients that are selected to receive a grant.

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: Dental History

Your Dental History

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

What is your age range? *

Are you currently employed? *

Next: Procedures

Your Dental Procedure

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

Do you have dental insurance?

Other insurance (please specify) *

What type of work are you looking for? * *

Other Procedure (optional)

Agree & Apply

By submitting an application to the Cosmetic Dentistry Grants program, you agree to abide by the terms of service. Please do not submit your application more than one time, otherwise your application will be discarded.

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.