Patient_Registration

Dental Consent Form

SCHOOL INFORMATION

Please Select the County your School is in, OR Special Event you are Registering For

Please Select your School, OR the Event Name

*If you are signing up for the school year, please select your county and school.

**If you are signing up for a special event, select "Special Events" instead of county, and then select the specific Special Event from the drop-down menu.

School

Grade

County

Teacher

N/A if you dont know

CHILD'S INFORMATION

Patient First Name

Middle Name

Patient Last Name

Patient Date of Birth

Gender

Male Female

Please list names & ages of other family members

PARENT/GUARDIAN INFORMATION

First Name

Last Name

Address

City

Zip Code

Home Phone

Cell Phone

Check all the ways we can communicate with you

ALL Cell Only Email Only

Please list any individuals/relatives that we can communicate with regarding child’s dental healthcare:

1.

2.

3.

PAYMENT INFORMATION

DENTAL SAFARI COMPANY, a fully licensed, professional corporation, will be at your child’s school. By signing this consent form, your child receives an exam by a licensed dentist or a (PHDH) Public Health Dental Hygienist, a cleaning, Fluoride, sealants and SDF caries treatment as needed. ALL CHILDREN ARE ELIGIBLE

Is child eligible for Free/Reduced lunch?

Yes No

Is child enrolled in state Medicaid program (Medical Card / All Kids)?

Yes No

Is child covered under Private Insurance?

Yes No

Self Pay

Reduced Fee - $75

Pay now by Credit Card or PayPal (www.DentalSafariCompany.com) Pay later by Credit Card or PayPal (You will be invoiced by text message or email one week before services)

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

Medical Card KidCare / All Kids Card RECIPIENT ID# (9-digit ID# 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

First Name

Middle Name

Last Name

Address

City

Zip Code

Phone

Social Security #

Employer

Card Holder Birth Date

Member ID#

Group #

Dental Insurance Company

Insurance Company Phone

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

HEALTH HISTORY

Does child need premedication with antibiotics for dental treatment? If yes, call (618) 993-8333

Yes No

Has your child had any history of the following? Check ALL that apply:

Other

Please explain any checked responses

Is child allergic to ANY medications?

Yes No

Please list:

Is the child taking ANY over-the-counter OR prescription medications at this time?

Yes No

Please list:

Does your child have any speech difficulties?

Yes No

Has your child ever suffered injuries to the mouth, head, or teeth?

Yes No

Does child’s home have well water?

Yes No

Are there any special instructions we should be aware of?

Yes No

FORM COMPLETION

Dental Examination may include being seen by a PHDH (Public Health Dental Hygienist) and reviewed by a licensed Dentist as directed by (IDPH) Illinois Department of Public Health https://dph.illinois.gov.

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

Check One: TOTAL CARE or PREVENTIVE CARE

TOTAL CARE (Preventive + Restorative) - Child receives: exam, cleaning, Fluoride, and appropriate x-rays, sealants and SDF (topical cavity treatment) AND, appropriate fillings, crowns, pulpotomies, baby teeth extractions (with or without space maintainers). PREVENTIVE CARE (Preventive Only) - Child receives: exam, cleaning, Fluoride, and appropriate x-rays, sealants and SDF (topical cavity treatment).

Required

Comments/Concerns:

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

Dental Safari Company Notice of Privacy Practices

By signing this consent form, I consent for my child to receive treatment checked above.

I give permission for Dental Safari to treat my child twice and understand my HIPAA rights at www.DentalSafariCompany.com

Signature

Clear

Clear

Required

Date

Form signed by:

Relationship to Patient:

Email

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.

Yes No

Signature

Clear

Clear

Required

Date

Dental Consent Form

SCHOOL INFORMATION

CHILD'S INFORMATION

PARENT/GUARDIAN INFORMATION

PAYMENT INFORMATION

Self Pay

PRIVATE INSURANCE INFORMATION

HEALTH HISTORY

FORM COMPLETION

Optional: Photo/Video Release for Minor Child

Please rotate your device.