Please click here to download Smiles From the Heart application form (PDF)
At Smile Doctors, we believe in the power of a smile to change lives! We created the Smiles From The Heart Program to make orthodontic treatment accessible to more families. We love to see our patients change as their teeth change! Please understand that we receive many applications for this program. Recipients are chosen based on a variety of factors. Smiles From The Heart applications are reviewed quarterly and Parents/Guardians are notified directly.
___ Application: Completed as directed in Black/Blue ink
___ Applicant Essay: Please provide handwritten essay describing how orthodontic treatment will change your life and how you will pay it forward.
___ Report Card: Please provide your most recent Report Card.
___ 2 Photos: Close-up images of Applicant while smiling.
• Applicant must reside within a reasonable distance to our clinic locations.
• Applicant must be between the ages of 11 – 18.
• Have healthy dental hygiene practices and had a dental check-up within the past six months.
• Must have a need for orthodontic treatment.
• Must currently be enrolled in school.
• Must follow and abide by treatment plan set forth by the orthodontist.
Smile Doctors Smiles From The Heart Program Patient Guidelines
1. Smile Doctors “Smiles From The Heart” Program provides for orthodontic treatment only. Extractions, dental cleanings, oral surgery, periodontal therapy, and any other treatment that may be necessary before, during, or after orthodontic treatment are the financial responsibility of the patient’s parents or legal guardians.
2. If your child has cavities or periodontal disease (gum disease), these conditions must be completely remedied before orthodontic treatment begins. If cavities or periodontal disease occurs during treatment, then braces will need to be removed and treatment stopped.
3. Your child must have a general dentist to verify that all necessary dental treatment has been completed before orthodontic treatment begins. In addition, your child must maintain regular dental appointments and cleanings during orthodontic treatment.
4. During the course of treatment, cavities can form around the braces if your child has poor oral hygiene. If your child does not maintain proper oral hygiene or if cavities form which are not remedied, the treating orthodontist has the option to remove the braces and end the orthodontic treatment. Your child will then be dismissed from the Smiles From The Heart Program.
5. If your child is accepted into the Smiles From The Heart Program, orthodontic treatment will be provided by the assigned orthodontist only. If you move away from the treating orthodontist, the Smiles From The Heart Coordinator will attempt to find your child another treating orthodontist; however, Smiles From The Heart cannot guarantee that this will be possible. If you move before the orthodontic treatment finishes and Smiles From The Heart is unable to find a new orthodontist, you must advise your treating orthodontist and make any arrangements necessary to complete treatment. This includes finding a new orthodontist, which will become your financial responsibility, or having the current orthodontist remove the braces.
6. Regular orthodontic appointments are necessary to make sure the teeth move as expected and no unwanted movement occurs. It is your responsibility to make sure that all of the scheduled appointments are kept. Failure to maintain regularly-scheduled appointments on a continued basis is grounds for the treating orthodontist to remove the braces and end the orthodontic treatment.
7. You and your child must completely follow the treatment plan recommended by your orthodontist, which will be explained to you before orthodontic treatment begins. If you fail to follow the treatment plan, the treating orthodontist has the option to refuse treatment, to remove the braces, and to end the orthodontic treatment.
8. During the course of orthodontic treatment, a trusting relationship between providers and patients is vital to the success of the outcome of the case. Patients must maintain excellent hygiene by brushing and flossing and by wearing appliances and rubber bands as instructed. Failure to comply with the treatment plan or maintain proper behavior so that the treatment can be delivered can result in refusal to continue orthodontic treatment or removing the braces and ending treatment.
9. Broken appliances or loose brackets and bands can cause damage to the teeth and the rest of the mouth. All patients must take special care not to eat hard or sticky foods or pull on the braces. If there is frequent damage to the appliances, the treating orthodontist has the option of removing the braces or charging you to repair the damage, which is not covered by the Smiles From The Heart Program.
10. One retainer, which is necessary to keep the teeth from shifting, will be provided as part of orthodontic treatment at no charge. If the retainer is damaged or lost, a fee will be assessed to fabricate a replacement.
11. Recipients of the Smiles From The Heart program are expected to become advocates of the practice and may be asked to assist in promotional events and media events.
12. If a Smiles From The Heart recipient is awarded treatment for Phase 1 treatment, an additional Smiles From The Heart application and process will need to be completed for Phase 2. A second Smiles From The Heart award isn’t guaranteed should Phase 2 treatment be necessary.