Step 1 of 425%About You:Name* First Last Age*Gender*FemaleMaleOccupation*Phone*Email* Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Do you speak fluent English?*YesNoPlease indicate your household income:*$0-20,000$20,000-40,000$40,000-60,000$60,000-80,000$80,000-100,000$100,000+ Program InterestHow did you hear about the Smile Again program?*Tell us why restoring your smile is important to you:*Tell us about an example of 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.*If any, please indicate how many teeth you are missing and where.*Of the remaining teeth in your mouth, please indicate how many teeth are damaged and where.*Please provide a photo that shows the current state of your teeth.*Will you be available to attend regular appointments at our practice?*YesNo Tell Us About Your Dental History:When was your last dental visit?* Tell us about your dental health:*Have you ever taken medication for osteoporosis?*YesNoHave you ever had any radiation to the head, neck, or face?*YesNoDo you have any bleeding disorders or take any blood thinners?*YesNoAre you currently a smoker?*YesNoIf yes, how many packs a week?Are you an insulin-dependent diabetic?*YesNoAre you or have you ever had problems with substance abuse?*YesNoDo you have or have you ever had an eating disorder?*YesNoPlease list all medications you are taking:* I have read and agree to the Terms and Conditions of the Smile Again program (listed below).* I agreePlease review the official Terms and Conditions of the Smile Again program before submitting your initial application.