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The OAAG proudly welcomes Dr. Ronald H. Van Slooten of Ho-Ho-Kus, NJ as a participating dentist.
Dec 12, 2012

The OAAG proudly welcomes Dr. Adam Lublin of Brooklyn as a participating dentist.
Dec 3, 2012

The OAAG proudly welcomes Dr. Harry Harcsztark of Kearny NJ as a participating dentist.
Nov 28, 2012

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First Name:
Last Name:
Address:
Apt/Suite:
- Leave blank if none.
City:
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ZIP/Postal Code:
Home Phone:
Mobile Phone:
Work Phone:
Ext.
Email Address:
Are you employed?
Yes   No
If Yes, please indicate your Occupation.
Work Place
Postal / Zip Code:
(Used to determine your proximity to a dentist)
Do you have a regular dentist?
Yes   No    Age:  
Would you like to complete your treatment plan in advance of a special occasion? (e.g.: Wedding)
If so, please provide details or enter ‘No Event’ in the space provided:
Please identify the type of procedure(s) you are seeking (if unsure, please leave blank):
Teeth Whitening Invisalign® Dental Bridge
Implant(s) Veneers Crowns (caps)
Other (Please state)
When was your last visit to the dentist?
Do you have dental insurance?
Yes - PPO
Yes - HMO
Yes - Other
(Please identify)
No
How long have you been dissatisfied with your teeth?
When would you like to begin treatment?

Oral Aesthetic Advocacy Group Inc (OAAG)
Grant Applicant / Recipient Agreement

 
Date of Board Approval: June 1st, 2010

As an applicant, or potential recipient of a grant from the OAAG, I agree to the following terms:

   1. I certify that any funds which may be disbursed to me by the OAAG will be used only for the purpose of a cosmetic dental treatment plan.
      
   2. Should I not undertake the procedure within 3 months of receipt of the Grant proceeds, I will forego my award.

   3. I understand that any proceeds I may receive from the Cosmetic Dentistry Grant Program can only be applied toward Cosmetic Procedures and that I am responsible for any basic dentistry costs such as fillings, root canals, extractions and teeth cleaning.
      
   4. I am responsible for informing the OAAG of any change or changes in my name or address during the period of time comprised of applying for a Cosmetic Dentistry Grant, and receipt of any Grant proceeds that may be awarded.
      
   5. I agree that OAAG may provide my information to authorized dental practitioners, their respective staff, third-party agents, volunteers or subsidiaries, for the purpose of booking my assessment and consultation, and to communicate with me regarding the status of my grant application; and/or to perform functions such as customer service, etc.
      
   6. I agree to allow the OAAG to publicize the disbursement of funds to me without prior notification to me. (We will not identify the nature of your treatment.)
      
   7. I agree that the OAAG may use my name, as well as other independently gathered information about me that is already in the public domain.
      
   8. I am aware that this includes, but is not restricted to, publication in the OAAG Newsletter, Corporate Sponsorship campaign advertisements, letters and brochures.
      
   9. If I am awarded a Grant, I will write a thank-you letter to the Organization that acknowledges the award. The Grant proceeds will not be awarded unless/until a thank-you letter is received.

   10. I certify that I am at least 18 years of age.

Submitting an application for a Cosmetic Dentistry Grant confirms you have read, understand and agree to the terms of these guidelines and agree to comply with them.
Agree & Apply