Give Back a Smile Patient Application
Click above to download the PDF application or call 800.773.4227
Who is Eligible?
(Program applicants must meet all criteria)
- Adult (18+) women and men who have received dental injuries to any of the front 8 teeth only, (otherwise known as the "smile-zone") from: former intimate partner or spouse (husband, wife, boyfriend, or girlfriend), family member, or sexual violence (sexual assault and/or rape).
- If hurt by an intimate partner or spouse: you must be out of all abusive relationships for at least one year, unless the abuser has died or is in jail/prison.
- If hurt by a family member: you must have lived in a separate home from that person for at least one year.
- If hurt because of sexual assault: it must have happened at least one year ago.
- All applicants must meet with a domestic violence/sexual assault advocate, social worker, counselor, minister, therapist or doctor at least once, to complete the application.
- The program does not help with cavities, gum disease, jaw injuries, or orthodontic treatment (braces, shifted teeth, and/or spaces between teeth).
- The program does not replace or fix dental work. In other words, dental work that does not fit, looks bad, no longer works, an implant that was started but not completed or any work that has been completed by a GBAS dentist in the past.
|In order to apply for the program, one of the following must be fulfilled:
- Pay a $20.00 application fee paid by money order only, to the GBAS program
- Or, complete 10 hours of community service before sending in your application
How Does it Work?
- Potential applicants click here to download the Patient Application (PDF) or call (800) 773-4227 to receive an application for the GBAS program.
- Mail completed form to: GBAS, 402 West Wilson Street, Madison, WI 53703 or fax to (888) 488-6888. (DO NOT fax application if including a money order.)
- Once we receive your application, you will be sent a letter within 30 days letting you know if you initially qualify or not. By filling out an application, you are not guaranteed free dental work.
- GBAS reviews applications first. If you initially qualify, you will be sent to a volunteer dentist who decides if you will receive care based on our guidelines. This is a volunteer program and the dentist decides what kind of dental work fits within the guidelines. You are not accepted into the program until the dentist sees you for a consultation. (Note: Referrals are based on volunteer availability, the GBAS volunteer list cannot be released.)
- It is the applicant’s responsibility to contact the dentist for an appointment.
- Not showing up for appointments, or last minute cancellations will result in disqualification.
- Email GBAS or call (800) 773.4227 for more information or questions about the GBAS patient application process.
Domestic Violence/Sexual Assault Agency Resources
Is it our hope that our services can be useful for the clients you serve. To request printed literature for your agency, please email us.