Free Braces S4L Form

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Please do not proceed if you don't have all these items saved on your phone or computer in .pdf, .jpeg, .doc, .docxYou'll need to upload these information later in this form. Please go to https://www.justsmileortho.com/pictureyourteeth for instructions on taking pictures of your teeth
2 letters of recommendations
Your School Report Card
3 photos your teeth (Front, Upper teeth, Lower teeth)
Information about where you're going to volunteer for community service
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Take a photo of the Applicant's teeth (Front)* This field is required.Bite on your back teeth completely and retract your cheeks with your fingers. Take picture of the Front of your Teeth.
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Take a photo of the Applicant's Upper Teeth* This field is required.Look up, Open mouth wide and take picture of the Tops of your UpperTeeth. Make sure all teeth are visible and not blurry. Retract your lips as necessary.
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Take a photo of the Applicant's Lower Teeth* This field is required.Look down, Open mouth wide and take picture of the Bottoms of your Lower Teeth. Make sure all teeth are visible and not blurry. Retract your lips as necessary.
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Patient Full Name* This field is required.
First Name
Last Name
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Mobile Phone Number* This field is required.Cell Phone # of person responsible
Area Code
Phone Number
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Your Child's birthdate* This field is required.
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Your Child's Mobile PhoneOnly for text appointment reminders if your child drives themselves
Area Code
Phone Number
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What is your child's gender?* This field is required.
Male
Female
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Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Email* This field is required.
example@example.com
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Check the conditions that apply to your child :* This field is required.Scroll down for more options
No Medical Problems, I'm healthy
Asthma
Diabetes
Hypertension/High Blood Pressure
Heart disease/Heart Attack/Sroke
Artificial Joints/Valves
Heart Murmur
Congenital Heart Defect/Heart Surgery/Pacemaker
Psychiatric disorder
Epilepsy/Seizure/Fainting
Cancer/Chemotherapy/Radiation Therapy
Hepatitis
HIV/AIDS
Kidney Problems
Sinus Problems
Arthritis
Abnormal bleeding
Ever had injury to mouth, teeth or chin
Hearing impairment
I may need Antibiotic Premedication prior to invasive dental treatments
Autism
Other
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Is your child currently taking any medication?* This field is required.
Yes
No
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What medications are you (or your child) taking?Please list medications below. Skip if none.
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Mother's information* This field is required.(or legal guardian. Type "na" if not available)
Mother's name
Mother's Mobile phone #
Mother's date of birth
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Father's information* This field is required.(or legal guardian. Type "na" if not available)
Father's name
Father's Mobile phone #
Father's date of birth
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Does your child have any allergies?* This field is required.Scroll down for more options
No I'm not allergic to anything
Aspirin
Codeine
Tetracycline
Dental Anesthetics
Metal
Erythromycin
Penicillin
Amoxicillin
Latex
Other
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Does your child use tobacco products?* This field is required.Cigarettes, cigars, chewing tobacco etc.
YESNO
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Does your child have jaw joint (TMJ) problem?* This field is required.Scroll down for more options
No TMJ issues that I know of
Clicking
Popping
Lock jaw
Pain
I grind my teeth
Other
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Who is your child's general dentist?* This field is required.Type "none" if you don't have one
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Does the Applicant have cavities?* This field is required.Did the dentist say they have cavities that needs filling? How many? When will they be done?
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Does the Applicant have baby teeth?* This field is required.Did the dentist tell you? How many?
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Who is your employer (for parent /legal guardian)?* This field is required.
You can also use: None, Student, Self-employed etc.
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What is your monthly income?* This field is required.Please include both parents per month
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Are you receiving these Benefits?* This field is required.
Food Stamps
Other
School Lunch Program
State provided Childcare
AHCCCS Medical/Dental
None
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Household* This field is required.
How many people in your household?
How many adults in your household?
How many children in your household?
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Do you have Orthodontic Insurance?* This field is required.
YESNO
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Insurance information (front picture of card)For your convenience take a photo of the FRONT of your insurance card (Optional): We can estimate your coverage if you provide the following information about your insurance company
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Insurance information (back picture of card)Take photo of the BACK of your insurance card (Optional): We can estimate your coverage if you provide the following information about your insurance company
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Are you the policyholder?* This field is required.
YESNO
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Insurance company information (Self)We can estimate your coverage if you provide the following information about your insurance company (You can skip this if you took a photo of your insurance card previously):
Ins Name
Ins Address
Ins Phone #
Group #
Policy/ins #
Your SS# or ID#
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Insurance company information (Policyholder)We can estimate your coverage if you provide the following information about your insurance company (You can skip this if you took a photo of your insurance card previously):
Ins Name
Ins Address
Ins Phone #
Group #
Policy/insurance #
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Policyholder information We can estimate your coverage if you provide the following information about the Policyholder:
Name
Birthdate
Employer
SS# or ID#
Relationship of policyholder to patient
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Emergency contactIn an urgent situation, is there someone who lives near you that we should contact?
Name
Relationship
Please enter phone # for emergency contact
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What is your main orthodontic concern?What would you like Dr Leo to address?
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Tell us about yourself* This field is required.Child Applicant: What do you like to do? Favorite hobbies, extracurricular activities, and the type of goals and aspirations in life, etc.
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Tell us about your family* This field is required.Child Applicant: How many siblings do you have, who are they, do they live with you, what do you like to do together, etc?
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Why do you want braces?* This field is required.Child Applicant: Please tell us in detail, why you would like braces and how will it change your life?
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Pay it Forward Community Service* This field is required.In our community, and all over the world, there is a great need for a great many of things. Being able to help those in need raises awareness and hope in the community and gives us, as individuals, the opportunity to reflect on our own needs versus those of others. We would like to hear from you! Take some time to reflect on the needs of your community. This will take some time and research on your part. Read your local newspaper, talk to a teacher or friend and choose a non-profit /charitable organization you feel you can impact the most in your community or the world. Think of it as a business plan for your soul! If selected, 40 hours of community service served by the Applicant will be requested during treatment durationNote: It is important to find something that touches your heart and you are passionate about. For instance, if you love animals, help at a local animal shelter. If you relate to being hungry or even homeless, find a shelter or food bank you can support. The most important thing is that you connect to your community and know that you are making a difference. Here are some ideas for you to get started:Collect and donate goods: Check with a local charity, church, shelter, humane society or orphanage if they need anything. (1) Non-perishable food, hygiene items, clothing or toys they are in need of. (2) Check around your house and see if there are things that are gently used/loved but no longer need. (3) Check with neighbors, let them know what you are doing and ask if they can help. (4) Collect treats, magazines, and hygiene items for soldiers deployed overseas or something to remind them of home. Donate your time: Check with a local charity, church, shelter, humane society or orphanage if they need volunteers. Every little bit helps (you can help out in your church such as cleaning and serving the poor and homeless but please note that proselytizing is not considered volunteer work) (1) Sweeping, Mopping or reorganizing can help considerably when it comes to redistributing goods. (2) Take dogs for a walk or refilling their water and food dishes. Just petting and spending time with them so they know they are loved. (3) Helping a school teacher with his/her classroom will help significantly. (4) Organizing books and more at a public or school library. For more specific non-profits in your area, please go to: WWW.ALLFORGOOD.ORG WWW.SERVE.GOV WWW.VOLUNTEERMATCH.ORG
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My Plan to Pay it Forward (Child Applicant)* This field is required.Who: Name of organization you'll be volunteering in. What is their mission statement?
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My Plan to Pay it Forward (Child Applicant)* This field is required.What: What does the organization need help with? What will you be doing?
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My Plan to Pay it Forward (Child Applicant)* This field is required.When: When will you volunteer? What hours and days will you be there?
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My Plan to Pay it Forward (Child Applicant)* This field is required.Why: What is most important to you about helping this organization?
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Free Braces Scholarship CONTRACT* This field is required.If selected from the pool of applicants by the board members of Smile for a Lifetime Foundation and by Just Smile Orthodontics to receive orthodontic treatment there are a few guidelines required for treatment. Throughout the selection process there is some professional guidance, if requested, but the decision is largely subjective and based on the completeness of the application, commentary, personal essay, character and the accompanying letters of recommendation submitted with your packet. Orthodontic treatment for the Greater Tucson Smile for a Lifetime Foundation will be provided by Board Certified orthodontist, Dr. Leo Toureno of Just Smile Orthodontics. By submitting and signing this application you understand and agree to the following: (1) I agree that appointments will be at the discretion of Just Smile Orthodontics (2) I understand that this can mean scheduling appointments during non-peak hours i.e. 10AM-3PM Tuesday through Thursday. No Saturday appointments. (3) I acknowledge that appointments must be kept in order to achieve an expeditious and desirable result. (4) I also understand that keeping appointments is essential to treatment success and is a requirement of accepting care from Dr. Leo Toureno. (5) If you must reschedule appointments, give Dr. Leo Toureno at least 24 hours’ notice. If more than two appointments are missed or appointments are constantly rescheduled it will be considered out of compliance which is grounds for removal of braces and revocation of scholarship. (6) If you must relocate prior to the conclusion of treatment, Smile for a Lifetime will do its best to find another service provider. However, it is not guaranteed that Smile for a Lifetime will have another provider available in the area and/or can continue to provide treatment as a result. (7) One set of clear retainers will be provided as a part of the scholarship award, any replacements will not be covered by Just Smile Orthodontics or Smile for a Lifetime. (8) Direct responsibilities of the patient: (a) Maintain excellent oral hygiene (tooth brushing, Flossing). If unwilling to meet expectations, due to medical and dental health risks treatment will be discontinued. (b) Follow the rules for eating habits. This will greatly reduce breakage of appliances (i.e. braces) and it is necessary for satisfactory completion of treatment.(c) Cooperate. More than four (4) loose brackets may be deemed sufficient evidence that cooperation is not sufficient to meet minimal requirements for treatment. (d) Other cooperation issues are with failure to cooperate with maintenance of auxiliaries including elastics, wearing head gear, facemasks and springs. (e) Attitude. You will be expected to maintain an exceptionally appreciative and respectful attitude once accepted into orthodontic treatment or any other aspect of treatment supported by Dr. Leo Toureno or Smile for a Lifetime. Rude behavior or an inappreciative attitude is unacceptable. (9) ATTENTION: Failure to comply with your responsibilities may result in removal of orthodontic equipment and discontinuation of treatment (10) ATTENTION: Honesty is expected. Any misrepresentation, falsification or exclusion of income will be grounds for dismissal from the program. Future applications will not be considered. There are many deserving children who are in need of orthodontics we are here to serve those in greatest need. (11) Media Disclaimer: If your child is the chosen applicant, you consent to Smile for a Lifetime’s (S4L) use, without charge, of all photos, video and audio recordings of your child. S4L may, (a) Copyright, broadcast, display, publish, re-publish and reproduce your child’s image, voice and any statements made by him/her, in whole or in part, in any and all media forms; and (b) Assign your child a fictitious name or use his/her first name, likeness, video, photograph, voice, statements and biographic or other information concerning his/her participation with S4L for fundraising or other promotional and advertising purposes. You and your child also agree to participate in surveys and case management during and after receiving treatment. (11) Legal Guardian Consent: I certify that I am the legal guardian of the child listed on this application. I have all rights and authority to make medical decisions for the child, that all information in this application is true and correct.This scholarship is intended specifically for underserved and deserving children in the community. There are many children who need and deserve an award winning smile and while we do our best to serve those greatest in need, it is a competitive process and not everyone will receive a scholarship. Please take your time on your application, your time and effort will be taken into consideration when selecting applicants for scholarship
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Privacy Notice Acknowledgement* This field is required.Please click on the link below to read how we protect your private information.
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Signature (Parent or Legal Guardian)The information, health history and preceding answers are true and correct to the best of my knowledge. I authorize and give consent to perform dental/orthodontic services agreed between doctor and patient to be necessary or advisable. If my child ever have any changes in their health or if their medication changes I will, without fail, inform the doctor at their next appointment.
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Signature (Applicant)The information, health history and preceding answers are true and correct to the best of my knowledge. I authorize and give consent to perform dental/orthodontic services agreed between doctor and patient to be necessary or advisable. I agree to be an appreciative and compliant patient, keep my teeth & braces clean, come to my appointments on time and not break any braces. If I ever have any changes in my health or if my medication changes I will, without fail, inform the doctor at my next appointment.
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Your name* This field is required.Name of adult person filling this form out
First Name
Last Name
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Total Income per month* This field is required.Please report total income for both parents per month
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Date* This field is required.
Date
Year
Month
Day
Should be Empty: