Step 1 of 425%About You:Name* First Last Age*Gender*FemaleMaleOccupation*Phone*Email* Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Do you speak fluent English?*YesNoPlease indicate your household income:*$0-20,000$20,000-40,000$40,000-60,000$60,000-80,000$80,000-100,000$100,000+ Program InterestHow did you hear about the Second Chance program?*Tell us why restoring your smile is important to you:*Tell us about an example of an obstacle in your life that you had to overcome or plan to overcome in the future. This does not need to be smile related. We just want to get to know you better.*If any, please indicate how many teeth you are missing and where.*Of the remaining teeth in your mouth, please indicate how many teeth are damaged and where.*Please provide a photo that shows the current state of your teeth.*Will you be available to attend regular appointments at our practice?*YesNo Tell Us About Your Dental History:When was your last dental visit?* Tell us about your dental health:*Have you ever taken medication for osteoporosis?*YesNoHave you ever had any radiation to the head, neck, or face?*YesNoDo you have any bleeding disorders or take any blood thinners?*YesNoAre you currently a smoker?*YesNoIf yes, how many packs a week?Are you an insulin-dependent diabetic?*YesNoAre you or have you ever had problems with substance abuse?*YesNoDo you have or have you ever had an eating disorder?*YesNoPlease list all medications you are taking:* I have read and agree to the Terms and Conditions of the Second Chance program (listed below).* I agreePlease review the official Terms and Conditions of the Second Chance program before submitting your initial application.