Austin Smiles Jaw Surgery Program Interest Form

Please read the descriptions of the following programs and select the ones you're interested in.

Mentorship Program

This program would connect you with a mentor, who is past jaw surgery patient. Through one-on-one Zoom meetings, you will get to ask them questions and hear a more personal perspective of the jaw surgery experience. Possible topics would include: how to mentally prepare for surgery, recovery tips, and more. You will have 1-3 meetings with your mentor.

If the participant is under 18 years old, an Austin Smiles Staff member will join all meetings between the mentor and participant.

Support Group

Connect with other teens to discuss your questions and concerns about jaw surgery! This support group will be faciliated by a past jaw surgery patient, and will be over Zoom. Possible topics would include: how to mentally prepare for surgery, recovery tips, and more. Meetings are expected to be held quarterly (every 3 months).

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Participants must be scheduled for a jaw surgery, or be expecting to undergo this medical procedure to qualify. If you have any questions, please contact us via email at info@austinsmiles.org or call us at (512) 451-9300.

Select the program(s) you are interested in:

Name

First NameLast Name

Date of Birth

Participant's Email

example@example.com

Guardian's Email

(required for participants under 18)

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Guardian's Phone Number

Required for participant's under 18Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

Postal / Zip Code

Which race or ethnicity best describes the patient?

When is your jaw surgery happening?

Date of Jaw Surgery (if scheduled)

Date

Do you have a preference over the gender of your mentor?

General Scheduling

Scheduling - Female Mentor

Scheduling - Male Mentor

Are there any topics you would like to discuss in this meeting?