Dental Consent Form


N/A if you dont know




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

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.


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.


Please send a photo of your state medical card to:


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:



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

I am a custodial parent or legal guardian of the minor child named above. I authorize and consent to this child receiving an exam, cleaning, Fluoride, sealants and SDF caries treatment 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.


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.

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