Dentist Referral Form

Gifted Smiles is a program of the American Association of Orthodontists Foundation

Your patient has applied to receive donated orthodontic services. Please complete this referral form on their behalf. 

Gifted Smiles is a program of the American Association of Orthodontists Foundation (AAOF), with a goal of providing orthodontic treatment to children whose need is significant enough to suffer detrimental dental and/or social effects. Thank you for taking the time to thoughtfully consider your response

Century Club

* Is the patient in need of orthodontic treatment?

* Is the patient motivated to receive orthodontic treatment?

* Does the patient's family keep appointments?

* Is the patient carries free?

* Does the patient have good oral hygiene?

Description of Patient's Current Condition

Detention

Malocclusion

Spacing

Crowding

Overjet

Crossbite

Overbite

Misalignment

Dentist Name

Security Measure

Thank you for your assistance. If you have any questions, please contact us directly at 1.800.424.2841 x582