Grant Applicant / Recipient Agreement
Last Date of Board Approval: February 5th, 2019.
As an applicant, or potential recipient of a Dental Grant, You agree to the following terms:
1. You understand that any funds or considerations which may be provided to You can only be applied toward the cosmetic dentistry treatment plan presented by a participating dentist of this Program.
2. Following Your examination, You must notify the Program Consultant if You wish to accept treatment. Failure to accept treatment may result in the forfeiture or indefinite delay of the Grant.
3. You understand that any proceeds or considerations You receive can only be applied toward cosmetic dentistry procedures and that You are responsible for any basic dentistry costs such as fillings, root canals, extractions and teeth cleanings that are not incidental to the cosmetic dentistry work.
4. You understand that You are financially responsible for the portion of your Treatment plan that is not covered by the Grant.
5. If requested, you agree to demonstrate your financial ability to complete payment for the portion of the treatment plan not covered by the Grant.
6. You agree that we may provide your information to authorized dental practitioners, their respective staff, third-party agents, volunteers or subsidiaries, for the purpose of booking your assessment and to communicate with You regarding the status of Your grant application; and/or to perform functions such as customer service, etc.
7. You agree to allow us to publicize the disbursement of funds to You without prior notification to You. (We will not identify the nature of your treatment.)
8. You agree that we may use your name, as well as other independently gathered information about You that is already in the public domain.
9. You agree to permit us to contact you and communicate with you via telephone, email, text messaging and regular mail.
10. You certify that You are at least 18 years of age.
Submitting an application for a Dental Grant confirms you have read, understand and agree to the terms of these guidelines and agree to comply with them.