AACD Charitable Foundation

AACD Charitable Foundation

Give Back a Smile Patient Application

The Give Back a Smile program was established to connect eligible survivors of domestic and/or sexual violence who've received dental injuries from the abuse with volunteer cosmetic dentists throughout the United States and Canada. Services are based on volunteer availability at the time you apply. If we do not have an available volunteer located within 200 miles of your location, we, unfortunately, cannot provide you services. Please be aware that our volunteer pool is more limited if you need dental care beyond the front 8 teeth. 

Since the program's inception, more than 1,600 smiles have been restored valued at more than $16 million in donated dental services. 
Give Back a Smile Application

Click above to download the PDF application or call 800.773.4227

Who is Eligible? 

(Program applicants must meet all criteria)
  • Adult (18+) women and men who have received dental injuries to the smile-zone from: former intimate partner or spouse (husband, domestic partner, wife, boyfriend, or girlfriend), family member, or sexual violence (sexual assault and/or rape).  
  • If hurt by an intimate partner or spouse: you need to be out of all abusive relationships for a minimum of one year. 
  • If hurt by a family member: you need to have lived in a separate home from that person for a minimum of one year. 
  • If hurt because of sexual assault: it needs to have happened at least one year ago. 
  • All applicants need to meet with a domestic violence/sexual assault advocate, case manager, counselor, faith leader, therapist or doctor with experience in counseling survivors of domestic violence/sexual assault, at least once.
  • The program does not help with dental neglect (such as cavities), gum disease, jaw injuries, or orthodontic treatment (braces, shifted teeth, and/or spaces between teeth).
  • The program does not replace or fix previous dental work done by any dentist. 
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 sending in 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.)
  • Once we receive your application, you will be sent a letter letting you know if you initially qualify or not. By filling out an application, you are not guaranteed free dental work. 
  • GBAS reviews applications first. If you initially qualify, you will be sent to a volunteer dentist who decides if you will receive care based on our guidelines. This is a volunteer program and the dentist decides what kind of dental work fits within the guidelines. You are not accepted into the program until the dentist sees you for a consultation.  (Note: Referrals are based on volunteer availability, the GBAS volunteer list cannot be released.)
  • The program does not guarantee implants or patient requested dental work. 
  • It is the applicant’s responsibility to contact the dentist for an appointment.
  • Not showing up for appointments, or last-minute cancellations can result in disqualification.
  • Email GBAS or call (800) 773.4227 for more information or questions about the GBAS patient application process.

Domestic Violence/Sexual Assault Agency Resources

Is it our hope that our services can be useful for the clients you serve. To request printed literature for your agency, please email us.  

How You Can Help


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