First Name *

Last Name *

Date of birth *

Occupation *

Employer

Email *

Phone *

Address

Street Address

City

State

Country

Postal Code

Who is your dentist? *

When was your last dental visit? *

How did you hear about the AZOMS New Smile Giveaway?

Tell us about your dental health *

Tell us why restoring your smile is important to you: *

Tell us about an obstacle in your life that you had to overcome or plan to overcome in the future. This does not need to be smile-related. We just want to get to know you better. *

Why do you think you are a good candidate for our Second Chance program? *

Were you affected by COVID-19? If so, how? *

Please indicate how many teeth you are missing, if any: *

Of the remaining teeth in your mouth, please indicate how many teeth are damaged: *

Please describe where your missing or damaged teeth are in your mouth (upper teeth, lower teeth, front, sides, etc.).

Will you be available to attend regular appointments at our practice? *

Yes

No

Have you ever taken medication for osteoporosis? *

Yes

No

Have you ever had any radiation to the head, neck, or face? *

Yes

No

Do you have any bleeding disorders or take any blood thinners? *

Yes

No

Are you currently pregnant or planning to become pregnant in the next 6 months? *

Yes

No

Have you smoked regularly in the past? *

Yes

No

Are you currently a smoker? *

Yes

No

Are you an insulin-dependent diabetic? *

Yes

No

Do you now or have you ever had problems with substance abuse? *

Yes

No

Please list all medications you are taking: *

Do you speak fluent English? *

Yes

No

Have you ever been convicted of a crime and/or is there a pending litigation against you or someone in your household? *

Yes

No

Please indicate your household income:

Please provide one clear photo of your face and smile.

Please provide one clear photo showing your missing or damaged teeth.

Signature *

Clear

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

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