Patient Application for Care

In partnership with Fusion Dental Implants

Your Information1

Dental History2

Your Story3

Photos & Documents4

Privacy & Consent5

Media Release6

Review & Submit7

Personal Information

All information is collected securely and protected under HIPAA. Fields marked with * are required.

First Name *

Last Name *

Preferred Name

Date of Birth *

Preferred Language

Phone *

Street Address *

City *

State

ZIP *

I need an interpreter

Emergency Contact

Name *

Phone *

Relationship

Financial Information

Eligibility is based on household income. This information is used solely for determining program eligibility and is kept confidential.

Household Size *

Annual Household Income *

Primary Income Source

Dental Insurance?

Medi-Cal

Medicare

Your Contribution

Our 30/70 funding model works best when patients can contribute toward their care. Any amount helps — even a small contribution shows your commitment and strengthens your case with donors.

I am able to contribute some amount toward my dental treatment

This is not required, and saying no will not disqualify you.

Demographics (Voluntary)

This information is entirely optional and will not affect your eligibility. It helps the foundation report aggregate data to grant funders.

Gender

Race/Ethnicity

Veteran

Experiencing Homelessness

Domestic Violence Survivor

Formerly Incarcerated

Referral Information

How did you hear about us?

Referring Organization

This application is protected by HIPAA (45 CFR Part 164) and CCPA (CA Civil Code 1798.100+). All data is encrypted in transit and at rest. The Smile Again Foundation is a registered 501(c)(3) nonprofit organization. Tax ID: 33-4244037.