Dental Bridges Grant ApplicationThank you for your interest in the Cosmetic Dentistry Grants Program!Apply to receive financial assistance for a dental bridge 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 dental bridges! Our application will only take a few minutes to fill out. Please start by providing your contact information below:Name & Contact First Name * Last Name * Email * Phone Number * Next: AddressThe 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 InformationHi 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 * - Select -CaliforniaNew JerseyNevadaNew YorkPennsylvaniaTexasFloridaVirginiaDistrict of ColumbiaMarylandAlabamaAlaskaArizonaArkansasColoradoConnecticutDelawareGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNew HampshireNew MexicoNorth CarolinaNorth DakotaOhioOklahomaOregonRhode IslandSouth CarolinaSouth DakotaTennesseeUtahVermontWashingtonWest VirginiaWisconsinWyoming Zip Code * Next: EmploymentEmployment InformationGreat, thanks. Let’s review your current work information: Are you employed? * - Select -YesNoRetired What is your occupation? * Work Phone Number * Work Phone Extension Work Zip Code * Next: Dental HistoryYour Dental HistoryOK, 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? * - Select -Less Than One YearTwo YearsThree YearsFour YearsMore Than Five Years What is your age range? * - Select -18 - 2526 - 3435 - 4546 - 5556 - 6565+ When was your Last visit to the dentist? * - Select -Less than 6 months6 months - 1 year1 - 3 yearsOver 3 years Do you have dental insurance? - Select -Yes - PPOYes - HMOYes - Other (Please identify)NoMedicaidMedicare Other insurance (please specify) * Next: ProceduresYour Dental ProcedureOK, we’re almost done! Please indicate which dental procedures you are most interested in. Please select one or more procedures *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. Emergency Dental CareTeeth WhiteningInvisalign®Dental BridgeDenturesImplant(s)VeneersCrowns (caps)PartialsAll on 4 ImplantsOther Other insurance (please specify) * Additional CommentsPlease provide any additional information we should know, including if your treatment plan is in advance of a special occasion or any other special circumstances. Where did you hear about us? * - Select -GoogleReferralDental Office ReferralFriend or Family MemberInstagramFacebookYoutube Agree & Apply I agree to the terms and conditions. SubmitThank You, NAMEYour 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.