GIVE BACK A SMILE APPLICATION PAGE 1 OF 4

Give Back A Smile Application Instructions

Please keep this page for your future reference and records.

1. Read the Give Back A Smile (GBAS) application carefully before filling it out.
2. Do not forget to sign and date the application.
3. Make an appointment with a counselor, domestic violence advocate, social worker, or
therapist.
4. Have the counselor, domestic violence advocate, social worker, minister or
therapist, complete the advocate section of the application and attach a business
card.
5. Make a copy of the completed application for your own files.
6. Mail or Fax the completed application to: Give Back A Smile, 5401 World Dairy Dr.,
Madison, WI 53718 or Fax: 1-888-488-6888.
7. You will be notified in writing by GBAS that your application was received. If there is a
problem or a question with your application, it will be sent back to you or you will be asked
for clarification.
8. Once your application is complete and passed the initial review you will be sent a letter
with the treating dentist’s contact information. Once an appointment is made, please
notify the doctor’s office if you must cancel the appointment (not showing up without
calling is means for disqualification from the program).
9. If your address or phone number changes, please notify GBAS by calling 1-800-773-
4227.
10. GBAS conducts the initial review of the application however the dentist has the final say
as to the eligibility of the applicant. This is a volunteer program and the doctor will
determine what dental work they can or cannot provide. The applicant is not accepted
into the program until the dentist conducts the first consultation and develops the
treatment plan.

APPLICANTS MUST MEET THE FOLLOWING GUIDELINES TO QUALIFY:

1. The applicant must have received the injuries to their mouth from an abusive intimate
partner or spouse. For example, husband, wife, partner, boyfriend, girlfriend, someone the
applicant date or had a child with. Other situations, while traumatic, do not qualify. If the
injury was caused by child abuse, elder abuse, sibling abuse, caregiver abuse, parent
abuse, violent attacks not related to domestic violence, stranger assault or accidental
injury, the application will be denied.
2. The applicant must have been out of the relationship for at least one year. However, it
does not matter how long ago the applicant received the injury. An exception for a shorter
time may be given if the abuser is deceased or in prison.
3. All applicants must see a domestic violence advocate, social worker, counselor, minister
or therapist at least one time. The application will be returned if the domestic violence
advocate, social worker, counselor or therapist’s section is not completed properly. The
applicant can contact the National Domestic Violence Hotline at 1-800-799-7233 to get the
phone number of the nearest domestic violence agency.
GIVE BACK A SMILE APPLICATION PAGE 2 OF 4

FOR GBAS OFFICE USE ONLY

Date Received: Date Returned to Applicant:

Date Forwarded: Date Assigned Dentist:

Forwarded to: F2F SCORES Authorization Code:

If you need someone to help you fill out the application, check one of the following:
Si usted necesita que alguien ayude a llenar la aplicación, verifica uno de los siguiente:

_____English is not my native language and I need a translator.

Ingles no es mi idioma nativo y Yo necesito una traductora.

_____Physical or literacy challenges make it difficult to fill out the application alone.
Los Desafios de alfabetismo y problemas physicales hacen dificile llenar la aplicación sola.

Name of Helper:
Nombre de la persona que le ayudo llenar la llenar la aplicación

Phone Number of Helper:

Numero de telefono

If you change your address or phone number at all, notify GBAS as soon as possible or
your standing in the program could be jeopardized if we cannot contact you. If you do
not have a phone, please write down a phone number that we can leave a message for
you.

PLEASE PRINT

1. First Name:_____________________ Middle Initial:____ Last Name:_______________________

2. Mailing Address:
Street:_____________________________________________________ Apt. Number:_________
City:_______________________________ State:_________________ Zip Code: ____________

3. Home Phone:___________________________ Other Phone:_____________________________

4. (Optional) Email Address:__________________________________________________________

5. Are you willing to travel? (circle one) YES NO

GIVE BACK A SMILE APPLICATION PAGE 3 OF 4

6. Did you receive physical injuries from an intimate partner or spouse? (circle one) YES NO
If NO, explain____________________________________________________________________

7. Please list the date of separation from your abuser: MONTH: _______________ YEAR: ________
If less than one year from today’s date, check one:
____abuser is deceased ____abuser is imprisoned ____other, explain:_________________

8. Have you had prior cosmetic dental procedures following the injury to your teeth?
(circle one) YES NO Date:____________________________
If YES, explain:___________________________________________________________________

9. Describe your injury to your teeth (this does not include gum disease, tooth decay or TMJ).
PLEASE INCLUDE A PHOTO OF YOUR DAMAGED TEETH.
Date of injury:_________________ How many teeth are missing?_____________________
Do you have broken or damaged teeth?_______________________________________________
Description of injuries to the teeth:____________________________________________________
_______________________________________________________________________________

10. (Optional) Here you may provide any additional information regarding your injury or abuse that you
may think will help the GBAS staff and dentist while reviewing your application.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

11. Have you received injuries or scars to the face, head or neck? (circle one) YES NO
If YES, do you want more information regarding the Face To FACE program?
(circle one) YES NO

12. Have you received injuries to your skin (not of your face)? (circle one) YES NO
If YES, do you want more information regarding the SCORES program?
(circle one) YES NO

13. I verify that the statements on this application are true. I authorize the release of this
information to the AACD, the Give Back A Smile program, and the dentists providing the
medical care needed to repair the damage caused by domestic violence.

Yo verifico que todo lo anterior es cierto. Yo autorizo que esta informacion puede ser
distribuido a AACD, GBAS, y a los dentista que dan la atencion medica que se necesita
reparar el dano ocasionada por la violencia domestica.

SIGNATURE:____________________________________________ Date:__________________
SU Firma Fecha
GIVE BACK A SMILE APPLICATION PAGE 4 OF 4

THIS APPLICATION WILL BE RETURNED IF THIS SECTION IS NOT COMPLETED.

All applicants must see a counselor, advocate, social worker, therapist or minister at least one
time before the application is completed.
The applicant can either see someone they have talked with in the past or seek a referral to a local
domestic violence program. To find the phone number to a local domestic violence program, call
the National Domestic Violence Hotline at 1-800-799-7233.
If the counselor, advocate, social worker, therapist or minister needs more information about Give
Back A Smile program before completing the application, contact GBAS at 800-773-4227.
Please indicate your role by circling the one that best applies to your position:

Counselor Advocate Social Worker Therapist Minister Other

COMMENTS:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

I confirm that I have met with the Applicant at least once. Based solely on their explanation, I
believe their injuries were caused by domestic violence, and that they are now out of the abusive
relationship. My business card is attached as requested. If a business card is not available, I
understand that I may be contacted in order to verify my place of employment and signature.

Signature:___________________________________________ Date:__________________________
Print Name:__________________________________ Agency:_______________________________
Phone:____________________ Address:_________________________________________________
City:______________________________ State:___________________ Zip Code:_______________