[Secure Form] Second Chance 2024 (BOMS)

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

Age

Occupation

Employer

Are you active duty or a veteran?

Which branch of the armed forces did/do you serve?

Phone Number

City/town of residence

State of residence

Who is your dentist?

When was your last dental visit?

How did you hear about the Second Chance program?

Other

Tell us about your dental health:

Tell us why restoring your smile is important to you:

Tell us about an obstacle in your life that you had to overcome or plan to overcome in the future. This does not need to be smile-related. We just want to get to know you better.

Why do you think you are a good candidate for our Second Chance program?

Were you affected by COVID-19? If so, how?

Please indicate how many teeth you are missing, if any:

How many of your remaining teeth are damaged?

Please describe where your missing or damaged teeth are in your mouth.

Will you be available to attend regular appointments at our practice?

Have you ever taken medication for osteoporosis?

Have you ever had any radiation to the head, neck, or face?

Do you have any bleeding disorders or take any blood thinners?

Are you currently pregnant or planning to become pregnant in the next 6 months?

Are you currently a smoker?

Have you smoked regularly in the past?

Are you an insulin-dependent diabetic?

Do you now or have you ever had problems with substance abuse?

Please list all medications you are taking:

Do you speak fluent English?

Have you ever been convicted of a crime and/or is there a pending litigation against you or someone in your household?

If yes, please elaborate below.

Please indicate your household income:

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.

Click Here to Upload

Upload one clear photo showing your missing or damaged teeth. Upload File(s) up to 250MB. Please see the example below.

Click Here to Upload

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.

I have read and agree to the Terms and Conditions of the Second Chance program (listed below).

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.