Information to be Included in the Application
The application includes the following information:
- Patient Information Form: This gives us some basic information about you, your child, and your family – primarily how to contact you and any other decision-makers in your child’s life.
- 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 require 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 for both 2016 and 2015.
- 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, their goals for treatment, and the steps you both are prepared to take to ensure the treatment is successful.
Digital Photos: 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.
Click on a thumbnail below to view the image at full size
- Personal Reference Form: We require 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, what his/her character is, and what his/her attitude is toward seeing things through to completion, even if initial results are not dramatic. The letter is to be sealed, with the sender's signature over the seal, and is confidential; the person writing the letter should not discuss or share it with you.
- 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 publicity purposes.
- Dental Examination Form: To undertake your child’s treatment, we need to have a good understanding of his/her current and past dental health and his/her commitment to dental care. 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.
- Application Checklist: This checklist helps you keep track of the various forms and whether they have been submitted.
If you have any questions about the form, please contact by e-mail at firstname.lastname@example.org.