Application Form for Azalea Gum Treatment Project under Smiles-For-All-SmilesForAll

Points to note on application:

1. Applicants must meet the below criteria:

a. Aged 18 years or above based on proof of identity and suffer from severe periodontitis

b. Able to provide:

Acceptable proof of address (within recent 3 months)
Proof of applicant in receiving Comprehensive Social Security Assistance (“CSSA”) (“Certificate of Comprehensive Social Security Assistance Recipients (for Medical Waivers)" or “Notification of Successful Application") OR
Proof of applicant as residents of Public Rental Housing (Housing Department (HD) e-Payment Card or a copy of the tenancy agreement from the Hong Kong Housing Authority (HKHA) or the Hong Kong Housing Society (HKHS)) OR
Proof of applicant earning an income not exceeding the latest means-test threshold for public rental housing (payslip within recent 3 months or tax assessment of the latest year of assessment)

This project offers priority to applicants who are receiving CSSA or public rental housing.

c. Medically fit to receive dental treatments including minor oral surgeries

d. No history of smoking in the last 6 months

e. Present with at least 10 teeth and do not require full arch dentures

f. No history of previous periodontal therapy, implant placements or extensive crowns and bridgeworks

2. Generally speaking, application by e-mail will be processed within 10 working days and the acknowledgement letter will be sent to you by e-mail. If applicants do not receive notice 20 working days after submitting your application, please contact the clinic.

3. Please read through the “Personal data (Privacy Ordinance, Statement of Purpose” (Annex I) before completing this form.

4. Please fill in the corresponding personal information according to identification document, sign the form and provide contact details.

5. If necessary, IAD-MSC may contact the applicant (or its family members or friends) to provide further documents.

6. With a huge demand for our service, you may have to wait for quite some time to be screened by our dentists. We will inform you of the date of your screening oral examination by phone or e-mail once available.

7. Please note that if the data you provided on this application form is incomplete or inaccurate, or you did not submit copy of identity document, the application will be deemed invalid and will not be processed. In order to receive our services on the day of screening oral examination, applicants have to show the original copy of Hong Kong Identity Card and other proof of eligibility.

8. For contact details, please visit www.iad.facdent.hku.hk

9. In case of any disputes, IAD-MSC has the right to make the final decision on eligibility for treatment under the Azalea Gum Treatment Project.

Full Name(As show on HKID)

HKID Number

Date of Birth

Gender

Male

Female

Contact Phone No.

Email

Copy of HKID

Valid Proof of Address(within 3 months)

1.Proof of CSSA OR 2.Proof of Public Rental Housing OR 3.Proof of Income

If choose to upload Proof of Income, please specify number of family members:

Applicant is medically fit to receive dental treatments including minor oral surgeries

Yes

No

Applicant has no history of smoking in the past 6 months

Yes

No

Applicant presents with at least 10 teeth and does not require full arch denture

Yes

No

Applicant has not received periodontal therapy, implant placements, or extensive crowns and bridgeworks in the past

Yes

No

Applicant is competent and willing to follow the treatment plan and schedule

Yes

No

Applicant is competent and willing to maintain proper oral hygiene

Yes

No

Applicant has read through and understands the “Personal data Privacy Ordinance, Statement of Purpose” (https://shorturl.at/imz78)

Yes

No

Application Form for Azalea Gum Treatment Project under Smiles-For-All

Please confirm that the applicant has prepared the following documents:

Please declare the following facts truthfully: