[Secure Form] Smiles For Teachers 2021 (ROFS)

Section 1 of 1 in this document

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.

First Name

Last Name

Phone Number

School Name

School City

School State

Grade

Subject

How did you hear about the Smiles For Teachers program?

Other

Who is your general dentist?

When did you have your last dental cleaning?

Why are you applying for this smile makeover?

Tell us a little about the current state of your teeth and your need for a dental implant.

In a few sentences, please tell us why you became a teacher and what keeps you coming back day after day.

Please make sure you are clicking the upload button after you have selected your photo(s).

Upload a clear photo of your smile. Upload File(s) up to 250MB. Please see the example below.

Upload a 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 Smiles For Teachers program. Please indicate that you have read and agree to the updated Terms and Conditions.

I have read and agree to the Terms and Conditions of the Smiles For Teachers program (listed below).

Click here to review the Official Terms & Conditions .

You are required to fully review the Official Terms & Conditions of the Smiles For Teachers program prior to submitting your initial application.