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
“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
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.
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
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.