This form is best filled out on a desktop computer, but if you are on a mobile device, we recommend turning your phone to landscape mode for a smoother experience.
Please make sure to click the UPLOAD button after you have selected your photo.
Upload one clear photo of your smile. Upload File(s) up to 250MB. Please see the example below.
Upload one clear photo showing your missing or damaged teeth. Upload File(s) up to 250MB. Please see the example below.
Below are the updated Terms and Conditions for the Second Chance program. Please indicate that you have read and agree to the updated Terms and Conditions.
Click here to review the Official Terms & Conditions.
You are required to fully review the Official Terms & Conditions of the Second Chance program prior to submitting your initial application.