It's Time to Smile Application - 2024 GIVEAWAY

For several years, Advanced Oral Surgery & Dental Implant Studio has performed complimentary, life-changing surgery to those in need of better oral health. We encourage all members in our community that have missing or failing to apply for the It’s Time to Smile program. We will then choose one recipient to undergo full-arch restoration, a procedure that provides a new, fully functioning, healthy, and natural-looking smile. We are accepting applications from October 1st through October 25th. The recipient will be announced the week of November 18th.

Age

Occupation

Employer

Are you active duty or veteran?

Phone number

Dentist - If you do not have one, list none

How did you hear about our Smile Time Program?

Tell us about your dental health:

Why is restoring your smile 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 are you a good candidate for our Smile Time Program?

How many teeth are you missing, if any?

0-5

6-10

11-15

16-20

21-25

25+

How many of your remaining teeth are damaged?

0-5

6-10

11-15

16-20

21-25

25+

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

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

Yes

Have you ever taken medication for osteoporosis?

Yes

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

Yes

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

Yes

Are you currently pregnant or planning to become pregnant in the next 12 months?

Yes

Are you currently a smoker?

Yes

Have you smoked regularly in the past?

Yes

Are you an insulin-dependent diabetic?

Yes

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

Yes

Please list all medications you are taking:

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

Yes

Please indicate your household income:

$0-20,000

$20,000-40,000

$40,000-60,000

$60,000-80,000

$80,000+

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

I have read and agree to the Terms and Conditions of the Smile Time Program (listed below)

Yes

Click here to view the Official Terms & Conditions