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
“We accept cash or check if you arrange by calling our office at
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.
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.
Please send a photo of your state medical card to: MyCard@DentalSafariCompany.com
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
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
Also, gives permission for HFS, QA Audits and providers to return to your
school and re-check your child’s sealants.
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.
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.