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
Cash Payment Declaration/ 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, 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.
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,
and Sealants FOR THE FOLLOWING TIMES in the upcoming school year (twice
a school year, 6 months apart):
Click on the hyperlink to obtain a copy of our HIPAA statement:
By signing, you give permission to treat your child and understand your