Dental Consent Form

SCHOOL INFORMATION

CHILD'S INFORMATION

PARENT/GUARDIAN INFORMATION

PAYMENT INFORMATION

DENTAL SAFARI COMPANY, a fully licensed, professional corporation, will be at your child’s school. By signing this consent form, your child will receive a visual exam (no x-rays) by a licensed dentist, a cleaning, Fluoride, and sealants as needed. ALL CHILDREN ARE ELIGIBLE

Self Pay

“We accept cash or check if you arrange by calling our office at (618) 993-8333.”

Reduced Fee Waiver

For financial reasons, Parent/Guardian is unable to pay Full Price for dental services at this time. By filling in your name below, you are providing a signature to a legally binding document.

Required

Grant Fund

I am stating my child qualifies for Free/Reduced lunch but is not covered under the State Medical Card and they are not covered with Private Insurance.

Required

Please send a photo of your state medical card to: MyCard@DentalSafariCompany.com

PRIVATE INSURANCE INFORMATION

Most private insurance pays 100% on preventative services we perform (questions: call (618) 993-8333).

Please enter Primary Card Holder’s Information

Please send a photo of both sides of your insurance card to: MyCard@DentalSafariCompany.com

HEALTH HISTORY

Optional: Photo/Video Release for Minor Child

I, as parent/guardian, of the above child, give permission to Dental Safari Company to take and use pictures/ videos in promotional material with no compensation to me. NOTE: Your child’s name will not be used unless further permission is given.

Are you interested in a 6-month recall appointment

This includes: dental screening, cleaning, Fluoride and sealants by a Registered Dental Hygienist.

IMPORTANT: Parent/ Guardian Consent

I am a custodial or legal guardian of the minor child name above. By signing my name, I authorize and consent to this child receiving the dental treatment if Dental Safari Company returns to your child’s school.

Required

FORM COMPLETION

I am a custodial parent or legal guardian of the minor child named above. I authorize and consent to this child receiving a visual exam, cleaning, Fluoride, and sealants as needed.

Click on the hyperlink to obtain a copy of our HIPAA statement:

By signing, you give permission to treat your child and understand your HIPAA rights.

Also, gives permission for HFS, QA Audits and providers to return to your school and re-check your child’s sealants.

Required
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