Share a Smile Preliminary Application

Share a Smile

Preliminary Application

A dentist has nominated you to apply for the Georgia Dental Association Share a Smile Program. Please complete the application below. If you qualify for the program, you will receive a follow-up email requesting additional information required to complete your application.

Patient First Name*

Patient Last Name*

Street Address*

Apartment Unit, etc.*

City*

State*

Select or enter value

Zip*

County of Residence*

Phone Number*

Phone

Email address*

Statement of Need

Please state the financial challenges limiting your ability to access dental care.*

How will dental treatment impact your life (health, employment, etc.)?*

Program Eligibility

Name of referring dentist in Georgia*

Phone number of referring dental office

Phone

Referring Dentist Email*

Do you have private insurance?*

Yes

No

Are your covered by a dental benefits plan?*

Yes

No

Do you receive Medicare?*

Yes

No

Are you a military veteran?*

Yes

No

Do you receive veteran's benefits?

Yes

No

Are you eligible to work in the United States?*

Yes

No

If a minor, does minor receive Medicaid?*

Yes

No

Do you have medical documentation that dental care is required?

Yes

No

Do you receive Medicaid?*

Yes

No

Do you have a documented physical or intellectual disability?*

Yes

No

Do you consider your current income level to be low, moderate or high?*

Low

Moderate

High

Send me a copy of my responses

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