Synergi Smiles Volunteer Program Form

At Synergi Orthodontic Specialists, we believe smiles are meant to be shared—both in our office and in our community.

Our Synergi Smiles Volunteer Program celebrates patients who give back by volunteering their time to causes they care about. Patients who complete 25 verified volunteer hours may earn bonus Synergi Smile Stamps, which can be redeemed for gift cards and $100 in non-cash treatment-related credits that can be applied toward your contract, the Synergi store, or miscellaneous charges.

As part of the program, participants are invited to share their volunteer story so we can highlight their impact and inspire others.

Volunteer Details

Volunteer Name *

First

Last

Parent/Guardian Name (If Minor)

First

Last

Volunteer Email *

what (mm/dd/yyyy) Hours

Volunteer Phone

Volunteer Hours

Volunteer Organization Name

Volunteer Activity or Project

Tell us about what you did, why it matters to you, and what you learned.

Supervisor or Coordinator Name *

First

Last

Supervisor/Coordinator Phone

Supervisors/Coordinator Email *

Date Started (mm/dd/yyyy) *

Date Ended (mm/dd/yyyy) *

Total Hours Volunteered *

Upload Photos from the Volunteer Experience

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

I certify that

A minimum of 25 volunteer hours were completed
I give Synergi Ortho permission to use text and photo(s) from the volunteer experience on social media and marketing platforms
I understand volunteer rewards are subject to verification and approval

Schedule your smile assessment today!