Download Application Form (Smiles Ahead) - Smiles Ahead | Orthodontic

Guidelines
1. Smiles Ahead program provides orthodontic treatment only. If extractions, cleanings, or other treatment are
needed, this will be at the expense of the patient.
2. Cavities/periodontal disease must be treated prior to the braces.
3. See a dentist prior to the braces and every 6 months during treatment.
4. During treatment, if the patient’s teeth are not kept clean, the braces will be removed and you will be dismissed
from the program.
5. The patient encouraged to bring in their “Teacher’s Report” for Math and English for each appointment. Each
visit will be a $30 fee with the “Teachers’ Report”. If the patient does not bring in the report or there is a lack of
effort, there will be a $60 fee for that visit. (For summer months-June, July and August-the fee will be $30)
6. If you move away, you will need to find a new orthodontist, which becomes your financial responsibility, or have
the braces removed.
7. Keeping scheduled appointments and following the orthodontists’ instructions are very important for treatment
progress. The braces may be removed for repeated missed appointments.
8. Broken braces by eating hard/sticky foods or by pulling on the braces can cause damage and delay treatment. If
there are excessive broken braces, the braces may be removed or there will be additional charges for the repairs.
9. One set of retainers will be provided at the end of treatment (Cost of $30). If the retainers are damaged or lost,
you will be charged for the replacement.
10. Consent is given to use the patient’s name, photographs, case history and quotes for
promotional/business/fundraising purposes.
11. I give my content for the Smiles Ahead program to attain information about the candidate in order to determine
their eligibility.
The undersigned being the custodial parent/legal guardian of _____________________________________ has read and
understands the above rules and guidelines. I further agree that if treatment is stopped for not following the above rules
and guidelines, we (my child and I) will hold harmless and free from any liability the treating orthodontist and the St.
Elizabeth clinic/staff, for any damage or injury resulting from the termination of treatment. If approved, I hereby consent
to allow assigned orthodontist to provide orthodontic treatment for my child.
Custodial parent or legal guardian consent
Applicant (Child Consent)
Date: ______________
_____________________________________________
Signature
_____________________________________________
Printed Name
_______________________________________
Signature
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Printed Name