bracing kids for a better future…

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become a provider

Become an SCL Provider by completing the form below.

Doctor Full Name and Title*
Doctor First Name*
Doctor Middle Initial
Doctor Last Name*
Title*
- DDS
- DMD
- Other
Doctor Email*
Practice Name*
Practice Address*
main or admin office

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Office Phone Number*
Office Fax Number
Website*
Office Manager/Administrator Name*
First Last
Office Manager/Administrator Email*
Office Scheduler Name
First Last
Office Scheduler Email
Marketing Contact Name
First Last
Marketing Contact Email
Is your marketing person "in house" and part of your practice staff?
- Yes, they are here full time
- Yes, they are here part time
- Yes, but they also have other treatment responsibilities
- No, we work with outsourced marketing support
Do you have satellite offices?*
- Yes
- No
- Not yet, but it's in the plan
Where are your satellite offices located?
Do you have partner or associate orthodontists?*
- Yes
- No
- Not yet, but I plan to
Partner or Associate Doctor's Names
Do you have multi-lingual staff?*
- Yes
- No
What languages do they speak?
Where did you attend Orthodontic School?*
Where did you attend Dental School?*
What practice management software do you use?*
Who is your preferred supplier for hardware/brakets?*
How did you first hear about Smiles Change Lives? (please be specific)*
Orthodontist Provider Agreement*
- I agree to the Terms of Service
Welcome to Smiles Change Lives! We appreciate your willingness to become a provider and know you and your staff will experience great satisfaction providing orthodontic care for qualified children in your community. This document serves as our Provider Agreement outlining our program guidelines, expectations and benefits.
Signature
Date
add copy to be downloaded
words about taking kids*
- We'll take 4-7 kids per year
- We'll take 8-11 kids per year
- We'll take 12-19 kids per year
- We'll take 20+ kids per year
- We want to be the Top SCL Provider in our state - what will that take?
- Other:

CHANGING LIVES… ONE SMILE AT A TIME…

Alice W.

“Our son would have gone without braces if it wasn’t for SCL! Thankful for this program and staff that care. We are currently in treatment. It is already making a difference. ”

Alice W.

Alexandria W.

“Amazing program that has truly changed my life. Once I was accepted it was such an easy process. Thank you so much!! I would recommend any one with low income and bad teeth to go through the process.”

Alexandria W.

Tiffany L.

“Just had our last appointment. Being a school teacher I didn’t make a lot of money. This program allowed me to give my daughter a smile that she shares with everyone. Thanks.”

Tiffany L.

Daya G.

“I just had not one but two daughters finish having their braces on through Smiles Change Lives and we are so happy with the results. Thank you for providing this service!”

Alice W.

Judith W.

“This is an incredible organization with Orthodontists donating their skills to change children’s lives. More people in need should know about this fantastic program”

Judith W.

Alan P.

“My son has finally been accepted, approved, and assigned an orthodontist. He goes tomorrow for his first appointment to start getting his braces. Thanks SCL, you have made my son very happy.”

Alan P.

Joy S.

“I am so thankful for smiles change lives for helping a struggling mother out. What an amazing program that helps families.”

Joy S.

Shelly P.

“I cannot say enough GREAT things about this program! They have given both of my daughters a new outlook on life, & self confidence that I could never teach.”

Shelly P.

“I cannot say enough GREAT things about this program! They have given both of my daughters a new outlook on life, & self confidence that I could never teach.”

Shelly P.

Joy S.

“I am so thankful for smiles change lives for helping a struggling mother out. What an amazing program that helps families.”

Joy S.

Alan P.

“My son has finally been accepted, approved, and assigned an orthodontist. He goes tomorrow for his first appointment to start getting his braces. Thanks SCL, you have made my son very happy.”

Alan P.

Judith W.

“This is an incredible organization with Orthodontists donating their skills to change children’s lives. More people in need should know about this fantastic program”

Judith W.

Daya G.

“I just had not one but two daughters finish having their braces on through Smiles Change Lives and we are so happy with the results. Thank you for providing this service!”

Alice W.

Tiffany L.

“Just had our last appointment. Being a school teacher I didn’t make a lot of money. This program allowed me to give my daughter a smile that she shares with everyone. Thanks.”

Tiffany L.

Alexandria W.

Alice W.

“Our son would have gone without braces if it wasn’t for SCL! Thankful for this program and staff that care. We are currently in treatment. It is already making a difference. ”

Alice W.

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For Orthodontists
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