GBASGBAS Patient Application

Give Back a Smile Patient Application

Click here to download Patient Application (PDF) or call (800) 773-4227.

Who is Eligible?
(Program applicants must meet all criteria)

  • Adult women and men survivors who received dental injuries from a former intimate partner or spouse.
  • A survivor whose injuries are to the smile-zone only. The program does not replace work that has been already repaired through previous enrollment in the Give Back a Smile (GBAS) program or by the survivor’s own dentist.
  • Individuals that have been out of an abusive relationship for over one year. Applications will be accepted prior to the one-year mark but will be placed on a waiting list until the requirement has been met. Applicants are responsible for updating the GBAS program with all contact Information.
  • All applicants must have at least one interview to connect them with local resources, to confirm that the injuries were caused by intimate partner violence, and that the applicant has been out of an abusive relationship for at least one year. A signature from the counselor, advocate, social worker, or case manager must be provided on the application for acceptance into the program.
  • A survivor whose smile is compromised due to intimate partner violence, and not due to previous neglect.

"Its hard to put into words how much this opportunity has changed my life.  Even after completion of my new smile, it took time to realize that I no longer needed to place my hand in front of my mouth when speaking or laughing.  In addition to healing physically, the wounds that were most difficult to heal came from enduring so many years of emotional abuse.  Getting back my smile forced me to face and overcome many of my demons."  

"I am so thankful.  Not only did these people give me back my smile, but they also gave me back my life."

- GBAS Program Recipient

In order to apply for the program, one of the following must be fulfilled:
  • Pay a $20.00 application fee paid by money order only, to the GBAS program
  • Or, complete 10 hours of community service before submitting your application
How Does it Work?
  • Potential applicants click here to download the Patient Application (PDF) or call (800) 773-4227 to receive an application for the GBAS program.
  • Mail completed form to: GBAS, 402 West Wilson Street, Madison, WI 53703 or fax to (888) 488-6888. (DO NOT fax application if including a money order.)
  • If eligibility criteria are initially met, GBAS will contact a participating dentist closest to the applicant’s area to ask if he/she will accept the case. Please note, GBAS is a national program and referrals are based on volunteer availability. The GBAS volunteer list cannot be released. 
  • If accepted, GBAS will contact the applicant with the referral.
  • It is the applicant’s responsibility to contact the dentist for an appointment.
  • Services are not guartanteed; the volunteer dentist makes the final determination of eligibility for the program.
  • Not showing up for appointments, or last minute cancellations will result in disqualification.
E-mail GBAS or call (800) 773.4227 for more information or questions about the GBAS patient application process.