Program Forms

Dental Treatment Referral

Future Smiles is a prevention based dental hygiene program and does not provide restorative dental care (fillings/crowns).

If you do not have a dentist the following is a network of community dental clinics that can provide an annual dental examination by a dentist, treatment and restorative dental care.

Please take a dental referral form to your child’s dentist on their next appointment.

Consent Form

All children are required to have a current consent form filled out and on file before receiving any Future Smiles services.

You can fill this out in our office or print it and fill it out before your visit.

Privacy Notice

Future Smiles values the importance of your privacy and we are committed to protecting your personal information.

Please review our privacy notice to understand what information we may collect and how it is used, as well as how it is protected.