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Adobe PDF   Healthy Smiles Ontario – ApplicationThe file you are about to download will ONLY work properly if opened with an Adobe Reader 10 or later client. Please do not open this file in a browser.Fill, Print & Save2481.0 kb

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Classification / Identification:
 Form Number:014-4953-64EEdition date: 2015/12 
 Title:Healthy Smiles Ontario – Application
 Ministry:Health and Long-Term Care  
 Branch/ABC:Public Health  
 Program:Public Health  
 Purpose of Form:Main application form for the core services stream of the Healthy Smiles Ontario program. This form applies to: (A) applicants that have a valid SIN and have filed statement of income or tax return with CRA; OR (B) applicants who do not have a valid SIN or have not filed taxes with CRA. The Guarantor Section on the Application Form is required to support registration and eligibility adjudication.  

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