Step 1 of 616%Patient InformationChild's Name* First Last Child's Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Child's GenderMaleFemaleChild's Date of Birth* MM DD YYYYChild's Race and EthnicitySelect all that apply. Information collected will only be reported on a program scale and not connected to the individual recipient. American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Pacific Islander White or Caucasian Multi-Racial/Multi-Ethnic Other Dental InformationDoes your child have a dentist and/or has been seen recently in a dental clinic?*Please note: Your child will need to be seen by a dentist before acceptance into the DOS program. A dentist referral form is required.YesNoDentist's Contact InformationYour dentist or dental clinic will be asked to complete a DOS referral form. Name Phone Does your child recieve Medicaid benefits?YesNoDoes your child have dental insurance?YesNoHas your child been evaluated by an Orthodontist?YesNoIf yes, which Orthodontist did they see?Include the Orthodontist evaluation notes and/or pictures that show your child's orthodontic need.Briefly describe your child's dental needs: Where does the child reside?Completing this form means that you have rights to make medical decisions for the child.Child lives with one or both parentsChild lives with a guardian/family memberChild lives with a foster family/custody of the state Parent/Guardian InformationParent/Guardian #1 Name* First Last Relationship to Child Parent/Guardian Phone Number*Parent/Guardian Cell Phone NumberParent/Guardian Email Address Parent/Guardian #2 Name First Last Relationship to Child Parent/Guardian #2 Phone NumberParent/Guardian #2 Email Address Please list any adults that can recieve information regarding your child.List any relatives, step-parents, etc that can obtain information regarding the child and their DOS treatment.NamePhone NumberEmailRelationship Foster Care/State CustodyContact Name* First Last Relationship to Child Phone NumberCell Phone NumberEmail Address Do you have documentation that allows you to make medical decision for this child?*Please note: Guardians must be able to supply court documents for medical decisions.YesNoPlease attach a copy of the medical decision documentation.Please list anyone that can recieve information regarding this child.List any relatives, case managers, social workers, etc. that can obtain information regarding the child and their DOS treatment.NamePhone NumberEmailRelationship Financial InformationHousehold Members*List everyone living in the child's home (including parents and child requesting treatment).NameAgeRelationship to Child Sources of Household Income*Please include monthly household income. To add a household member, click the plus button to the side of the first row. If the category does not apply, just leave it blank.Household Member NameMonthly WagesSocial Security (SSI) AmountDisability (SSDI) AmountChild Support AmountUnemployment AmountTemporary Assistance (TANF) AmountOther Tax Return or SSI Awards LetterParent or guardians must attach a copy of last year's federal tax return (1040/1040EZ) or Social Security (SSI) awards letter with this application for review. Your child must be listed as a dependent in your household.Accepted file types: jpg, pdf. Program InformationChild's StatmentPlease upload the completed "About Your Child" Patient Questionnaire. If you need to email the form, send it to email@example.com with the child's first name, last initial in the subject line.Accepted file types: jpg, pdf, doc.How did you hear about the DOS program?How far will you travel for orthodontic treatment?Less than 10 miles from the child's home11-19 miles from the child's home20-25 miles from the child's homemore than 20 miles from the child's homeDoes your child have any special needs or medical concerns?Additional Information DOS Program RulesDOS Program Guidelines*1. Donated Orthodontic Services (DOS) provides for orthodontic treatment only. Extractions, dental cleanings, oral surgery, periodontal therapy, and any other treatment that may be necessary before, during, or after orthodontic treatment are the financial responsibility of the patient’s parents or legal guardians. 2. If your child has cavities or periodontal disease (gum disease), these conditions must be completely remedied before orthodontic treatment begins. 3. Your child must have a general dentist, who must verify that all necessary dental treatment has been completed before orthodontic treatment begins. In addition, your child must maintain regular dental appointments and cleanings during orthodontic treatment. 4. During treatment, if your child does not brush and floss properly, cavities can form around the braces. If your child does not maintain proper oral hygiene or if cavities form which are not remedied, the treating orthodontist has the option to remove the braces and end the orthodontic treatment. Your child may be dismissed from the DOS Program. 5. If your child is accepted into the DOS Program, orthodontic treatment will be provided by the assigned orthodontist only. If you move away from the treating orthodontist, the DOS Coordinator will attempt to find your child another treating orthodontist; however, DOS cannot guarantee that this will be possible. If you move before the orthodontic treatment finishes and DOS is unable to find a new orthodontist, you must advise your treating orthodontist and make any arrangements necessary to complete treatment, including finding a new orthodontist, which will become your financial responsibility, or having the current orthodontist remove the braces. 6. Regular orthodontic appointments are necessary to make sure the teeth move as expected and no unwanted movement occurs. Most of these appointments will be during school hours. It is your responsibility to make sure that all of the scheduled appointments are kept. Failure to maintain regularly scheduled appointments on a continued basis is grounds for the treating orthodontist to remove the braces and end the orthodontic treatment. 7. You and your child must completely follow the treatment plan recommended by your orthodontist. If you fail to follow the treatment plan, the treating orthodontist has the option to refuse to continue treatment, to remove the braces, and to end the orthodontic treatment. 8. During orthodontic treatment, your child must cooperate with the assigned orthodontist. Failure to cooperate fully with the orthodontist or to maintain proper behavior so that the treatment can be delivered can result in the orthodontist refusing to continue orthodontic treatment until the improper behavior is corrected or removing the braces and ending treatment. 9. Broken appliances or loose brackets and bands can cause damage to the teeth and the rest of the mouth. Your child must take special care not to eat hard or sticky foods or pull on the braces. If there is frequent damage to the braces, the treating orthodontist has the option of removing the braces or charging you to repair the damage, which is not covered by the DOS Program. 10. One retainer, which is necessary to keep the teeth from shifting, will be provided as part of orthodontic treatment at no charge. If the retainer is damaged or lost, you will be charged for a replacement retainer. My child and I have reviewed and agree.Please read the following statements. If you understand and agree to the conditions, please mark the "I agree" checkbox.*I understand that I will need to provide personal information that includes but is not limited to medical, dental, and financial condition. I give my consent for the program coordinator to obtain information from my child’s physician, dentist, contact people I listed, and/or government or private agencies in order to determine eligibility for the DOS program. I understand information provided by me or others as noted above may be given only to the volunteers involved in my child’s treatment and will be held confidential. I give permission for the program coordinator to share information about my child with one or more volunteer Orthodontists in the DOS program. I realize that the application to the DOS program does not assure my child will be referred for an examination or that he or she will be accepted as a patient following an examination. I understand that the American Association of Orthodontists (AAO), which coordinates the DOS program, will determine whether my child is eligible for the program and, if so, will seek to refer my child to a participating volunteer orthodontist. I further understand that the orthodontist, not the AAO, is solely responsible for diagnosis and any possible dental treatment that my child might receive. I understand that the orthodontist has volunteered to treat my child’s existing dental condition only and is not obligated to provide donated care in the future or to maintain my child as a patient. I understand the importance of keeping all scheduled appointments. Failure to do so, without at least 24 hour notice to the orthodontists, can disqualify my child from obtaining further treatment through the program. I agree that I will authorize the treating orthodontist to release necessary information regarding my child's patient status to the AAO DOS Program Coordinator throughout treatment. To the best of my knowledge, the information provided on this form is a full and accurate disclosure of my current physical, medical, and financial status. I agree This iframe contains the logic required to handle Ajax powered Gravity Forms.