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 caries free?

* Does the patient have good oral hygiene?

Description of Patient's Current Condition

* Dentition

* 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