Online Form Available: https://www.aaoinfo.org/_/donated-orthodontic-services/
Mail: AAO, Attn: Donated Orthodontic Services
401 North Lindbergh Blvd., St. Louis, MO 63141
Fax: Attn: Donated Orthodontic Services @ 314.689.0293
Questions: 1.800.424.2841 x582
Today’s Date:
Child’s Name:
DOB:
Child’s Address:
City:
State:
Zip:
Child’s Gender: Male Female Other__________________
Child’s Race and Ethnicity: Select all that apply. Information collected will only be reported on a program scale and not
connected to the individual recipient.
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Pacific Islander
White or Caucasian
Multi-Racial/Multi-Ethnic
Other_________________________________
Does your child have a dentist and/or has been seen recently in a
dental clinic?
Please note your child will need to be seen by a dentist before acceptance into the DOS program. A
dentist referral form is required.
Yes No
Dentist’s Contact Information
Your child’s dentist or dental clinic will need to complete a DOS referral form (last page of this document)
Dentist Name:__________________________________ Phone Number:______________________________
Does your child have Medicaid benefits? Yes No
Does your child have dental insurance? Yes No
Has your child been evaluated by an Orthodontist? Yes No
If yes, which Orthodontist did they see?
Briefly describe your child’s dental needs:
Where does your child reside? By completing this form you represent that you have legal rights to make medical decisions for the child.
Child lives with one or both parents
Child lives with a guardian/family member
Child lives with a foster family/custody of the state (skip to page 3)
Patient Application
1
Parent or guardians must attach a copy of the most recent year’s federal tax return (1040/1040EZ) or Social Security
(SSI) awards letter with this application for review. Your child must be listed as a dependent in your household.
Parent/Guardian Information
Parent/Guardian #1
Relationship to Child:
First Name:
Last Name:
Phone Number:
Cell Phone
Number:
Email Address:
Parent/Guardian #2
Relationship to Child:
First Name:
Last Name:
Phone Number:
Cell Phone
Number:
Email Address:
Please list any adults that can receive information regarding your child.
List any relative, step-parents, etc. that can obtain information regarding the child and their DOS treatment.
Name
Phone
Email
Relationship
Financial Information
Household Members: List everyone living in the child’s home (including parents and child requesting treatment). If more
room is needed, attach another sheet.
Name
Age
Relationship
Sources of Household Income
Please include monthly household income. If the category does not apply, just leave it blank. If you need additional space,
feel free to attach another page.
Household Member
Name (First, Last)
Monthly
Wages
Social
Security
(SSI)
Disability
(SSDI)
Child
Support
Unemployment
Temporary
Assistance
(TANF)
Other
$
$
$
$
$
$
$
$
$
$
$
$
$
$
2
Please attach a statement or letter from your child explaining: why they want braces and how they intend to care for
them. If you need to email the letter, send it to dos@aaortho.org with the child’s first name, last initial in the subject line.
Foster Care/State Custody Information
Contact Information
Relationship to Child:
First Name:
Last Name:
Phone Number:
Cell Phone Number:
Email Address:
Do you have legal documentation that allows you to make
medical decisions for this child?
Please attach a copy of the documentation.
Yes No
Please list any adults that can receive information regarding this child.
List any relatives, case managers, social workers, etc. that can obtain information regarding the child and their DOS
treatment.
Name
Phone
Email
Relationship
Program Information
How did you hear about the DOS Program?
How far will you travel for orthodontic treatment?
We will do our best to match you with a DOS provider close to your child’s home.
Less than 10 miles from the child’s home
11-19 miles from the child’s home
20-25 miles from the child’s home
More than 20 miles from the child’s home
Other:_____________________
Does your child have any special needs or medical concerns? If so, please explain.
Additional Information (share anything else you would like us to know)
3
DOS Program Guidelines
Please read the following statements.
If you understand and agree to the conditions, please mark the “I agree” checkbox.
I understand that I will need to provide personal information that includes but is not limited to medical, dental, and financial
condition.
I give my consent for the program coordinator to obtain information from my child’s physician, dentist, contact people I listed,
and/or government or private agencies in order to determine eligibility for the DOS program.
I understand information provided by me or others as noted above may be given only to the volunteers involved in my child’s
treatment and will be held confidential.
I give permission for the program coordinator to share information about my child with one or more volunteer Orthodontists in
the DOS program.
I realize that the application to the DOS program does not assure my child will be referred for an examination or that he or
she will be accepted as a patient following an examination.
I understand that the American Association of Orthodontists (AAO), which coordinates the DOS program, will determine
whether my child is eligible for the program and, if so, will seek to refer my child to a participating volunteer orthodontist. I
further understand that the orthodontist, not the AAO, is solely responsible for diagnosis and any possible dental treatment
that my child might receive.
I understand that the orthodontist has volunteered to treat my child’s existing dental condition only and is not obligated to
provide donated care in the future or to maintain my child as a patient.
I understand the importance of keeping all scheduled appointments. Failure to do so, without at least 24 hour notice to the
orthodontists, can disqualify my child from obtaining further treatment through the program.
To the best of my knowledge, the information provided on this form is a full and accurate disclosure of my current physical,
medical, and financial status.
I agree
Parent/Guardian Name (Please Print)
Parent/Guardian Signature
*Patient Name & Signature required if 18 years old.
Foster Parent/State Custody Name (Please Print)
Foster Parent/State Custody Signature
4
Please read the following DOS Program Rules with your child.
If you both understand and agree to the conditions, please sign below.
1. Donated Orthodontic Services (DOS) provides for orthodontic treatment only. Extractions, dental cleanings, oral surgery,
periodontal therapy, and any other treatment that may be necessary before, during, or after orthodontic treatment are the
financial responsibility of the patient’s parents or legal guardians.
2. If your child has cavities or periodontal disease (gum disease), these conditions must be completely remedied before
orthodontic treatment begins.
3. Your child must have a general dentist, who must verify that all necessary dental treatment has been completed before
orthodontic treatment begins. In addition, your child must maintain regular dental appointments and cleanings during
orthodontic treatment.
4. During treatment, if your child does not brush and floss properly, cavities can form around the braces. If your child does
not maintain proper oral hygiene or if cavities form which are not remedied, the treating orthodontist has the option to
remove the braces and end the orthodontic treatment. Your child may be dismissed from the DOS Program.
5. If your child is accepted into the DOS Program, orthodontic treatment will be provided by the assigned orthodontist only. If
you move away from the treating orthodontist, the DOS Coordinator will attempt to find your child another treating
orthodontist; however, DOS cannot guarantee that this will be possible. If you move before the orthodontic treatment finishes
and DOS is unable to find a new orthodontist, you must advise your treating orthodontist and make any arrangements
necessary to complete treatment, including finding a new orthodontist, which will become your financial responsibility, or
having the current orthodontist remove the braces.
6. Regular orthodontic appointments are necessary to make sure the teeth move as expected and no unwanted movement
occurs. Most of these appointments will be during school hours. It is your responsibility to make sure that all of the scheduled
appointments are kept. Failure to maintain regularly scheduled appointments on a continued basis is grounds for the treating
orthodontist to remove the braces and end the orthodontic treatment.
7. You and your child must completely follow the treatment plan recommended by your orthodontist. If you fail to follow the
treatment plan, the treating orthodontist has the option to refuse to continue treatment, to remove the braces, and to end the
orthodontic treatment.
8. During orthodontic treatment, your child must cooperate with the assigned orthodontist. Failure to cooperate fully with the
orthodontist or to maintain proper behavior so that the treatment can be delivered can result in the orthodontist refusing to
continue orthodontic treatment until the improper behavior is corrected or removing the braces and ending treatment.
9. Broken appliances or loose brackets and bands can cause damage to the teeth and the rest of the mouth. Your child must
take special care not to eat hard or sticky foods or pull on the braces. If there is frequent damage to the braces, the treating
orthodontist has the option of removing the braces or charging you to repair the damage, which is not covered by the DOS
Program.
10. One retainer, which is necessary to keep the teeth from shifting, will be provided as part of orthodontic treatment at no
charge. If the retainer is damaged or lost, you will be charged for a replacement retainer.
Adult’s Name (Please Print)
Adult’s Signature
Date
Child’s (Patient’s) Name (Please Print)
Child’s (Patient’s) Signature
Date
5
Mail: AAO, Attn: Donated Orthodontic Services
401 North Lindbergh Blvd., St. Louis, MO 63141
Fax: Attn: Donated Orthodontic Services @ 314.689.0293
Questions: 1.800.424.2841 x582
Today’s Date:
Patient Name:
DOB:
Date of last appointment:
How often is the patient seen in your office?
Does the patient’s family keep appointments?
Yes No
Is the patient in need of orthodontic treatment?
Yes No
Is the child motivated to receive orthodontic treatment?
Yes No
Description of Patient’s Current Condition:
Malocclusion
Class I
Class II
Class III
Spacing
Mild ≤ 3 mm
Moderate 4-6 mm
Severe ≥ 7 mm
Crowding
Mild ≤ 3 mm
Moderate 4-6 mm
Severe ≥ 7 mm
Overjet
Normal
Moderate 2-5mm
Severe ≥ 6mm
Crossbite
None
Anterior
Posterior
Overbite
Normal
Moderate (50-75%)
Severe > 75%
Open Bite
Misalignment
None
Mild
Moderate
Severe
Description of Dentition:
Primary
Mixed
Permanent
Is the patient carries free?
Yes No
Does the Patient have good oral hygiene?
Yes No
Comments:
Dentist Name (Please Print)
Dentist Signature
Dentist Phone Number
Thank you for your assistance!
Dentist Referral Form
Referring Dentist: Your patient has applied to
received Donated Orthodontic Services. Please
complete the referral form on their behalf.
