Please contact me about Smiles for life!

 

I would like to help children and whiten my smile.  I pledge to donate at least $250 to the Smiles for life! program once Dr. Ken Madison and his team perform a special teeth whitening treatment on my smile. 

This whitening service, which normally costs over $400, will be provided to me at no charge by Dr. Madison and his team, with DiscusDental donating the whitening materials.  All their time and expertise for this advanced cosmetic dental treatment is being donated to help sick and needy children. 

Please complete this form and then click on the Submit Form button. Someone from our office will contact you to arrange for your teeth whitening. The fields marked with an * are required. Thank you for supporting this worthwhile cause!

 

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