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 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
inhabitants
(small towns)
30,000 to 99,999
inhabitants
(larger towns)
100,000 to 499,999
inhabitants
(small cities)
Over 500,000
inhabitants
(larger cities)
2013 After-tax family income
1 person 12,935 14,803 16,514 16,723 19,774
2 persons 15,743 18,018 20,100 20,353 24,066
3 persons 19,604 22,434 25,028 25,344 29,968
4 persons 24,456 27,990 31,225 31,618 37,387
5 persons 27,849 31,872 35,556 36,004 42,572
6 persons 30,886 35,347 39,433 39,929 47,214
7 or more persons 33,922 38,822 43,309 43,854 51,855
2014 After-tax family income
1 person 13,187 15,093 16,837 17,050 20,160
2 persons 16,051 18,371 20,493 20,751 24,537
3 persons 19,987 22,873 25,517 25,839 30,554
4 persons 24,934 28,573 31,835 32,236 38,117
5 persons 28,394 32,496 36,252 36,707 43,404
6 persons 31,489 36,039 40,204 40,709 48,137
7 or more persons 34,585 39,581 44,156 44,711 52,868
  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 you and your child to share with us your 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 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.
  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 ask that your child's general dentist completes this form and shares 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 on a memory stick or CD, or can be e-mailed to administration@smiles4canada.ca.

 


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