Taylor's Smile Application

Thank you for your interest in Taylor's Smile. We know sharing your story can be personal, and we appreciate the trust you're placing in us. Please complete the application below as thoroughly as possible. Every application is reviewed with compassion, respect, and complete confidentiality.

Before You Apply

Taylor's Smile currently serves Massachusetts residents ages 18–35. Before applying, please be aware that applicants must:

• Have been evaluated by a dentist regarding their current dental concerns.

• Be willing and able to travel up to 100 miles for treatment, if necessary.

• Commit to attending all scheduled dental appointments and completing the full course of treatment.

• Be seeking smile restoration that aligns with Taylor's Smile's mission. Taylor's Smile does not provide dental implants or replace/redo existing cosmetic or restorative dental work.

Meeting these requirements does not guarantee acceptance into the Taylor's Smile program.

First Name

Last Name

Email Address

Phone Number

City, State

Age

Are you currently a Massachusetts resident?

What dental concerns would you most like Taylor's Smile to help address?

Share Your Story

Please tell us about yourself, the life experiences that have affected your smile, how your smile has impacted your confidence or daily life, and why receiving treatment would be meaningful to you.

Taylor's Smile helps provide restorative and cosmetic dental care to young adults whose natural smiles have been affected by life's experiences. Please ensure your request aligns with our mission and eligibility requirements before submitting your application.

Please upload one or more photos of your smile (optional)

Do you currently have a dentist or dental specialist?

Yes

Not sure

If yes, please provide the name and location of your dentist or dental practice.

Have you been evaluated by a dentist regarding your current dental concerns?

Yes

When was your most recent dental examination?

Have you had dental X-rays within the past 12 months?

Yes

Has a dentist recommended a specific treatment for you?

Yes

Not sure

If yes, please briefly describe the treatment your dentist has recommended.

Do you have a written treatment plan or cost estimate from a dentist?

Yes

Not sure

Do you currently have dental insurance?

Yes

Are you seeking dental implants as part of the treatment you are requesting?

Yes

Not sure

Are you seeking to replace or redo previous cosmetic or restorative dental work (such as crowns, veneers, bridges, or similar treatment)?

Yes

Not sure

If selected, are you willing and able to travel up to 100 miles for dental treatment if necessary?

Yes

Dental treatment may require multiple appointments over an extended period of time. If selected, do you agree to attend all scheduled dental appointments and complete the full course of treatment?

Yes

I understand that attending all scheduled dental appointments is required. Missed appointments or repeated cancellations without appropriate notice, except in the case of an emergency, may result in removal from the Taylor's Smile program.

I understand and agree

I understand that submitting an application does not guarantee acceptance into the Taylor's Smile program. Treatment options and eligibility are determined based on individual circumstances and the recommendations of participating dental professionals.

I understand and agree