Patient Registration Indiana

Dental Consent Form

SCHOOL INFORMATION

Please Select the County your School is in

Please Select your School

School

Grade

County

Teacher

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

PAYMENT INFORMATION

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

Is child eligible for Free/Reduced lunch?

Yes No

Is child enrolled in State Medicaid program (Medical Card / Hoosier Healthwise)?

Yes No

Is child covered under Private Insurance?

Yes No

Self Pay

Full Price - $128 Reduced Fee - $75 Must Sign Declaration below

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.”

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.

Signature

Clear

Clear

Required

Date

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.

Signature

Clear

Clear

Required

Date

Hoosier Healthwise RECIPIENT ID# (12-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

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

Date

FORM COMPLETION

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):

Fall Spring Both

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

Dental Safari Company Notice of Privacy Practices

By signing, you give permission to treat your child and understand your HIPAA rights.

Signature

Clear

Clear

Required

Date

Form signed by:

Relationship to Patient:

Email

Dental Consent Form

SCHOOL INFORMATION

CHILD'S INFORMATION

PARENT/GUARDIAN INFORMATION

PAYMENT INFORMATION

Self Pay

PRIVATE INSURANCE INFORMATION

HEALTH HISTORY

Optional: Photo/Video Release for Minor Child

FORM COMPLETION

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