top of page
Dental Grants

Request Your Own Dentist

State / Province

Please Read Before Submitting

To request your preferred dental clinic, please provide complete and accurate clinic details, including their valid email address and website. We are unable to process your request without this information.

If you do not have these details, please contact the clinic directly before submitting.

Once submitted, we will reach out to the clinic regarding enrollment and notify you as soon as we receive their response. Please do not submit a clinic that you have not attended as a patient.

When was the last time you attended this dental office?
Within the last 6 months
Within the last 12 months
1–2 years ago
More than 2 years ago
Select the option(s) that best describes the treatment(s) you are looking for.

The Dental Grant covers 25% of eligible professional fees. Patients are responsible for the remaining 75%, which can be covered using a mix of insurance, financing, and out-of-pocket options.

If you receive the 25% Grant, how soon until you're ready to begin treatment?
Immediately
Within 30 days
1-3 months
Just exploring
How do you expect to cover the remaining 75% of your treatment cost?
Are you financially able to proceed with treatment if the cost is reduced by the 25% grant but not fully covered?
Yes
No

Please confirm:

By sending this information, I authorize the Dental Grants Program to contact this clinic on my behalf regarding my application.

bottom of page