A Message to Smile Again Patients

You and your dentist are partners in maintaining your oral health, but you will ultimately ensure the success or failure of the treatment process. You will receive the best care possible; care that you truly deserve.

As a program partiicpant please be sure that you understand and agree to the following:

The objective of this program is to restore my oral health and to “normalize” my smile.
I am ready, willing and able to participate. Although all dental services are provided free of cost, I understand that I must make an investment in myself to be successful in this very special program.
I will keep all appointments, arrive on time and be respectful to my Smile Again dentist(s) and his/her staff(s). I understand that with just one missed appointment without proper notification and/or excessive appointment cancellations, I will be dismissed from the program.
I will follow all of my Smile Again dentist’s office policies. For example: Dental offices vary on policies for missed appointments. I will ask my dentist about his or her policy. Many dentists ask that you call to cancel an appointment at least 24 hours in advance. This will allow time for office staff to find someone else for your scheduled appointment. Those who don't call to cancel or excessively cancel will be dismissed from the program.
The intention of this program is to treat my existing dental problems only (related pain, function and appearance resulting from either domestic abuse trauma or neglect). It is not the program’s intention to provide ongoing donated care after my initial treatment is completed. Upon completion of this care, I will contact Smile Again Program representatives for information on Smile Again Program graduate opportunities for discounted dental check-ups.
I will keep my teeth clean and I will encourage my family to do the same. To maintain my dental health, I will practice good dental care at home between dental visits and follow my dentist's instructions.
All information is confidential, so I will be honest with my Smile Again dentist about my conditions, allergies, medications and/or past substance abuse to avoid serious complications.
I am aware that certain incidental costs (i.e., medication) - if any - will be my responsibility. I will discuss my ability to handle this responsibility with my Smile Again dentist before beginning and during treatment.
If I don't understand any part of what my Smile Again dentist recommends, I will ask for more information.
I have reliable transportation to get to and from my dental appointments and I have a reliable telephone number, so my Smile Again dentist’s office can get in touch with me during business hours (8 am to 5 pm, M-F).
My dental treatment may require many appointments over several weeks, months or possibly years and may involve several doctors.
After several visits to a dental office, my teeth/mouth will feel and look better – but I understand that my TREATMENT IS NOT COMPLETE UNTIL THE DENTIST SAYS SO. I will continue to see my dentist as long as it takes to complete treatment.
Dental care is a highly personalized health service; treatment varies from patient to patient.
The dental care provided through this program is just for me. I will not ask the dental office to provide care to my family or friends. For information on additional dental resources, contact (303) 488-9700 or click here.
I believe I have the ability to complete treatment (keeping all appointments, having reliable transportation and contact information, etc.).

Waiver and Release Form – you must give a signed copy of this form to your dental office at your first appointment and you must fax a signed copy to (303) 488-0177.

Satisfaction Interview – we want your feedback on your experience in the program, so please complete and return this form at the end of your treatment.