Thousands of people struggle with missing or damaged teeth but cannot afford treatment. At Save A Smile, we connect individuals in need with resources, professional volunteer dental care, and support to bring back their confidence and health. Comprehensive dental treatment is provided at no cost to approved applicants (please note: we do not provide purely cosmetic treatments).

Please fill out the form as accurately and completely as possible. Every detail helps us better understand your needs and coordinate your potential care.

• Step 1: Submission & Initial Review – Once you submit your completed form, our team will review it against our general eligibility guidelines.
• Step 2: The Compassionate Waitlist – If you meet the preliminary criteria, you will be placed on our waitlist in the order it was received. Please note: Placement on the waitlist does not guarantee approval. You will receive an status update within one month of submitting.
• Step 3: Patient Coordination & Consultation – When your application reaches the top of the list, a Save A Smile Coordinator will contact you for a detailed review. If eligible, you will be matched with a volunteer dental professional in your area for an initial consultation.
• Step 4: Final Acceptance – Final approval into the program is determined by the volunteer dentist after your initial consultation appointment.

⏱️ Estimated Time: It takes approximately 15–20 minutes to complete this application. You may save your progress at any time and return later—just ensure you click "Save Progress" before exiting.

We believe everyone deserves the chance to smile with confidence. To qualify for the Save A Smile program, you must meet at least one of the following primary criteria:

• 65 years of age or older
• Permanently disabled
• Require medically necessary dental care

• Financial Need: You must lack the financial means to afford necessary dental care.
• Insurance Utilization: All available dental insurance and alternative benefits (including Medicaid) must be exhausted prior to receiving care through Save A Smile.
• Program Limit: Services through our donated dental network can only be received once per individual.
• Provider Discretion: All treatments are subject to the evaluation and discretion of the volunteer dentist. Complex care, deep sedation, or specific restorative treatments may vary by provider.

Gathering these items beforehand will help you complete your application smoothly:

• Alternative Contact: Name and phone number for someone who can reach you if we can't.
• Medical Information: Your primary care physician’s name and phone number, alongside general diagnoses/disability details.
• Dental Concerns: A brief description of your current oral health issues.
• Financial Details: An itemized breakdown of your monthly income and living expenses.

You may be asked to upload or provide the following documents after submission:

• A breakdown of benefits or letters of denial from your dental insurance.
• Existing treatment plans from a dentist showing the remaining out-of-pocket balance.
• A Social Security Disability award letter (if under the age of 65).
• Form DD214 (for veterans).

Please select all options that apply to your current situation:

•  I am 65 years of age or older
•  I am permanently disabled
•  I have medical documentation stating that dental care is medically necessary
•  None of the above

Every smile matters. Thank you for reaching out to Save A Smile. saveasmilefoundation.org