AZOMS NEW SMILE

Providing A New Smile To One Lucky Patient

If you have teeth that need help, need dental implants, or are afraid to smile because of your oral health, our AZOMS NEW SMILE program may be your perfect opportunity. The selected recipient will receive a Straumann® Pro Arch Fixed Solution full-arch restoration procedure at no charge.

At Arizona Oral & Maxillofacial Surgeons, we believe everyone deserves to be confident and proud of their smile. We encourage you to apply and look forward to hearing your story.

Rules, Terms and Conditions

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Questions?

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Fill Out Our Form To Enter For Your Chance.

AZOMS NEW SMILE

form to enter into the AZOMS New Smile Giveaway.

Name(Required)

First Last

Age(Required)

Occupation(Required)

Employer

Optional

Phone(Required)

Email(Required)

Address(Required)

City State / Province / Region

Who is your dentist?(Required)

When was your last dental visit?(Required)

How did you hear about the AZOMS New Smile Giveaway?

Tell us about your dental health(Required)

Tell us why restoring your smile is important to you:(Required)

Tell us about an obstacle in your life that you had to overcome or plan to overcome in the future. This does not need to be smile-related. We just want to get to know you better.(Required)

Why do you think you are a good candidate for our Second Chance program?(Required)

Were you affected by COVID-19? If so, how?(Required)

Please indicate how many teeth you are missing, if any:(Required)

Of the remaining teeth in your mouth, please indicate how many teeth are damaged:(Required)

Please describe where your missing or damaged teeth are in your mouth (upper teeth, lower teeth, front, sides, etc.).

Will you be available to attend regular appointments at our practice?(Required)

Have you ever taken medication for osteoporosis?(Required)

Have you ever had any radiation to the head, neck, or face?(Required)

Do you have any bleeding disorders or take any blood thinners?(Required)

Are you currently pregnant or planning to become pregnant in the next 6 months?(Required)

Have you smoked regularly in the past?(Required)

Are you currently a smoker?(Required)

Are you an insulin-dependent diabetic?(Required)

Do you now or have you ever had problems with substance abuse?(Required)

Please list all medications you are taking:(Required)

Do you speak fluent English?(Required)

Have you ever been convicted of a crime and/or is there a pending litigation against you or someone in your household?(Required)

(if yes) Would you like to elaborate?

Please indicate your household income:

Please provide one clear photo of your face and smile.

Max. file size: 50 MB.

Please provide one clear photo showing your missing or damaged teeth.

Max. file size: 50 MB.

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AZOMS NEW SMILE

Providing A New Smile To One Lucky Patient

Rules, Terms and Conditions

Questions?

We Are Here To Help

Fill Out Our Form To Enter For Your Chance.

AZOMS NEW SMILE

Trusted care for all your
oral and maxillofacial needs.

Tucson Office

Hours

Oro Valley Office

Hours

Sahuarita Office

Hours

Contact Us

AZOMS NEW SMILE

Providing A New Smile To One Lucky Patient

Rules, Terms and Conditions

Questions?

We Are Here To Help

Fill Out Our Form To Enter For Your Chance.

AZOMS NEW SMILE

Trusted care for all your oral and maxillofacial needs.

Tucson Office

Hours

Oro Valley Office

Hours

Sahuarita Office

Hours

Contact Us

Trusted care for all your
oral and maxillofacial needs.