Orthodontic Assistance Application Child's Full Name Date of Birth Parent/Guardian Phone Number Email Address Home Address Total Number of People in Housould Total Annual Household Income Are you Currently Receiving government assistance? SNAP Medicaid Free/Reduced Lunch Other Name of Orthodontist Office Phone Number Has an orthodontic consultation been completed? Yes No Estimated Cost of Treatment Upload Treatment Plan (PDF or Photo) Please Share in (300 words or less): Why treatment is needed, How it would impact your child, Why financial assistance is necessary. I certify that the information provided is accurate. I understand funding is limited and not guaranteed. I consent to the verification of financial information. Send
