How do I complete the Smiles 4 Canada application?

You can download the application. It has 7 parts:

  1. Patient Information Form: This gives us some basic information about you, your child, and your family – primarily how to contact you and any other legal decision-makers in your child's life.
  2. Financial Information form: Smiles 4 Canada is targeted at lower-income families, specifically those whose total after-tax family income in the previous two taxation years is below the Federal Low Income Cut-Offs (LICO). To substantiate income, we ask you to provide information on the income for all your child's parents/guardians and a copy of the Canada Revenue Agency's Notice of Assessment. The table below provides information on LICO.
Size of family unit Community size
Rural areas
outside CMA or CA
Census Agglomeration (CA) Census Metropolitan Area (CMA)
Less than 30,000
(small towns)
30,000 to 99,999
(larger towns)
100,000 to 499,999
(small cities)
Over 500,000
(larger cities)
2016 After-tax family income
1 person 13,525 15,478 17,267 17,485 20,675
2 persons 16,461 18,840 21,016 21,281 25,163
3 persons 20,498 23,457 26,169 26,499 31,334
4 persons 25,571 29,266 32,649 33,060 39,092
5 persons 29,119 33,326 37,178 37,646 44,514
6 persons 32,294 36,959 41,232 41,750 49,367
7 or more persons 35,469 40,593 45,284 45,854 54,220
2015 After-tax family income
1 person 13,335 15,261 17,025 17,240 20,386
2 persons 16,230 18,576 20,722 20,982 24,811
3 persons 20,211 23,129 25,802 26,128 30,895
4 persons 25,213 28,856 32,191 32,596 38,544
5 persons 28,711 32,859 36,657 37,118 43,890
6 persons 31,841 36,441 40,654 41,165 48,675
7 or more persons 34,972 40,024 44,649 45,211 53,460
  1. Personal Statement Form: We want your child's treatment to be successful, and an important part of that success is his/her motivation – the more emotional investment your child has in the treatment, the greater the likelihood s/he will work cooperatively with the orthodontist and see it through to completion. In this form, we ask your child to share with us his/her reasons for receiving treatment and your goals for the treatment.
  2. Digital Photos Guide: To help us evaluate the severity of your child's dental problems, we ask that you send us at least 6 specific digital pictures; you are welcome to send more, but we need these 6 in order to determine the need and the amount of work to be done. The treating orthodontist will also need this information, plus any x-rays s/he may take, to develop a course of treatment.
  3. Personal Reference Form: We ask that you submit a personal reference for your child, to help us understand his/her character. The reference is in the form of a letter, written by someone other than a relative, explaining how the child is affected by his/her teeth and smile, and what his/her character is. The letter is to be sealed, with the sender's signature over the seal, and is confidential.
  4. Program Rules, Expectations and Release Form: This form constitutes an agreement between you, CFAO Smiles 4 Canada and the treating orthodontist. In it, you agree to ensure your child keeps his/her teeth clean, maintains his/her oral health, complies with the orthodontic treatment (including keeping all appointments, wearing retainers and rubber bands (if necessary)), and has any additional dental work that may be necessary. It also specifies what is included in the treatment, and what you might have to pay for separately. Finally, you are asked to give your consent on a number of important privacy considerations, including the disclosure of financial and health information to the Regional Committee that reviews the application and to the CFAO, and the use of case information that may be used for educational or pubilshing purposes.
  5. Dental Examination Form: To undertake your child's treatment, we need to have a good understanding of his/her current and past dental health. To do so, we require your child's general dentist to complete this form and share some basic dental health information with us. Please note: your dentist may charge for the completion of this form.
  6. Application Checklist: This checklist helps you keep track of the various forms and whether they have been submitted.

To download instructions on completing the application, please click here. Once you have all the information, you can send it to us at:

Smiles 4 Canada
c/o 2800 14th Avenue, Suite 210
Markham, ON L3R 0E4

The digital photos can be included with the application on a memory stick or CD, or can be e-mailed to


Share |
© 2018 Smiles 4 Canada