Forms and Applications

Here are links to forms and applications you may need for our Medication Assistance Program, Smiles for a Lifetime, or to donate to our mission.

Medication Assistance Program

Application Packet

Paquete de Solicitud 

Employer Statement of Income Form

No Household Income Form

Attestation of Physical Address/Patient Identification Form

Smiles for a Lifetime Program

Smiles Parent Permission Form

Donation Forms

Become a Champion Tribute Donation Form Declaration of Support Letter Fundraising for Welvista Toolkit Volunteer Interest Form

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If you are seeking information on your application status or are a patient with questions about your prescription(s), please call us at 803-933-9183.