1) Smiles4Canada covers the cost of orthodontic treatment only. Other dental treatment may be required for the orthodontics to be completed. This may include cleanings, fillings, extractions, gum surgery, root canals or jaw surgery. Smiles4Canada does not cover the cost of these other dental procedures. You and the patient agree to undertake the necessary treatment so that orthodontic treatment can proceed. *
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2) Orthodontic treatment can only be completed in the presence of ideal oral health. The patient is expected to maintain regular appointments with his/her general dentist and to comply with any treatment recommended by his/her general dentist.*
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3) The patient is expected to keep his/her mouth clean during orthodontic treatment. This reduces the risk of cavities and gum problems. If the treating orthodontist does not believe the mouth is being kept clean enough, treatment will be stopped and the braces will be removed. *
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4) The patient is expected to see his/her orthodontist regularly. This allows treatment to progress and reduces the risk of unwanted tooth movement. If the treating orthodontist finds the patient is not attending regular appointments, treatment will be stopped and the braces will be removed. *
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5) The patient is expected to follow the orthodontist's recommended treatment. The patient may be expected to wear rubber bands to help fix the position of his/her teeth. If the treating orthodontist does not believe the patient is wearing the rubber bands as required, treatment will be stopped and the braces will be removed.*
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6) The orthodontic office will make other recommendations regarding keeping the mouth healthy and clean, foods and drinks to avoid, emergencies with the braces, and appointment schedules. The patient agrees to follow all of the recommendations and policies of the orthodontic office.*
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7) The patient will be expected to wear retainers following orthodontic treatment. If the retainers are not worn as recommended by the orthodontist, the teeth will shift back to their original positions. The patient agrees to wear the retainers as recommended by the orthodontist. *
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8) The treatment provided through Smiles4Canada includes the cost of one set of retainers. If the retainers are damaged or lost, or simply wear out over time, a replacement set of retainers will be required. There will be an additional cost for any replacement retainers. *
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9) The orthodontic treatment will be provided by one orthodontic office. If the patient moves and is no longer able to visit the original office, Smiles4Canada may attempt to find another orthodontic office to complete the treatment; however, Smiles4Canada cannot guarantee that a new office will be found. If Smiles4Canada cannot find an orthodontist to complete the treatment, the patient will be responsible for finding his/her own way to complete the treatment, including any costs involved. *
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10) The patient will be expected to complete a short report at the end of his/her treatment, outlining how orthodontic treatment has helped him/her. The patient agrees to complete the report within 3 months of the completion of treatment. *
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11) I, the parent/guardian of the candidate, confirm the information provided in this application is accurate and complete. The application fully discloses all sources of financial support for the candidate and the family, and all relevant health information relating to the candidate. *
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12) If the candidate is accepted for treatment, I, the parent/guardian of the candidate, agree to pay a one-time administrative fee of $500 before treatment is commenced. I understand that treatment will not take place until this fee is paid in full and that, once treatment has commenced, the fee will not be refunded under any circumstances whatsoever. This includes if the braces are removed early for any of the reasons mentioned above. *
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13) If the applicant is accepted for treatment, I, the parent/guardian of the applicant, consent to the use of his/her name, case history, and testimonial to help promote the program. This may include postings on the program's website and/or other promotional materials. Images may be requested with further parental consent. *
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14) If there are more than one parent(s)/guardian(s), I, the parent/guardian of the applicant certify that I have discussed this application with the other parent(s)/guardian(s) and that they have consented to submission of this application. *
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15) I, the parent/guardian of the candidate, recognize and acknowledge that if we undertake paid orthodontic treatment for the candidate with any orthodontic or dental professional, our application to Smiles4Canada will be invalided and will not be eligible for the program. *
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16) By signing this form, you consent to act as the primary contact between Smiles4Canada and the candidate. Other family members who may attempt to communicate with Smiles4Canada will not receive a response. *
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17) By signing this form, you confirm that the family does not have the financial resources to afford treatment and that they have no way to proceed with threatment unless they are accepted into the program. *
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18) I accept that any false statements in this application will result in expulsion from the program at any time *
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