Consent Form

Parents/Guardian
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.

School Information

School: Sparta-lincoln Middle School

Grade:

County: Randolph

Teacher:

Payment Information

Method of Payment:

Child's Information

Child's Name:
*Please use the child's full, legal name.

First Name:

Middle Name:

Last Name:

Male
Female

Date of Birth:

Month:

Day:

Year:

Age(In Years):
    

Address 1:

Address 2:

Suite/Apt#:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Email:

Text Message Reminders?  Yes

Insurance Information

You have not selected that your child has private dental insurance.

Health Information

Does your child need to be premedicated before detal treatment?   Yes No
**IF YES - Please call our office at (618) 993-8333

HEALTH HISTORY - IMPORTANT. MUST BE FILLED OUT COMPLETELY
Has your child had any history of, or conditions related to, ANY of the following? Check ALL that apply:

AD/HD

Allergies (Seasonal)

Anemia

Asthma

Bleeding Disorders

Blood Disorders

Cancer

Cerebral Palsy

Chronic Sinusitis

Diabetes

Ear Aches

Epilepsy

Fainting

Growth Problems

Hearing

Heart

Heart Murmur

Latex Allergy

 Pregnancy (Teens)

Seizures

Thyroid

Tobacco / Drug Use

Other

Yes No  Is child allergic to ANY medication?

Yes No  Is child taking ANY over-the-counter OR prescription medications at this time?

Yes No  Does your child have any speech difficulties?

Yes No  Has your child ever suffered injuries to the mouth, head, or teeth?

What type of water does your child drink?
City Water   Well Water   Bottled Water   Filtered Water

IMPORTANT : PARENT / GUARDIAN SIGNATURE REQUIRED
I am a custodial parent or legal guardian of the minor child named above. I authorize and consent to this child receiving the dental treatment described, and allow the school nurse/school representative and dental provider access to child's dental record.

Signature

Relation to Child

Date
04/26/2024

*By typing your name above, you are providing a signature to a legally binding document.

Optional: Photo/Video

6-Month Recall? Release for Minor Child

Our company is establishing a 6-month recall program for schools that are interested.
Would you like your child to receive a dental cleaning and exam again in six months?

Yes   No   Undecided, would like more information

*The American Academy of Pediatric Dentistry (AAPD) recommends children visit the dentist at least every six months (twice a year).

Parent/Guardian:

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.

Signature:

*By signing, you give permission to treat your child and understand your HIPAA rights. [HIPAA form can be reviewed at www.DentalSafariCompany.com, or a copy can be sent to you by using DENTAL SAFARI COMPANY'S contact information at the top of this Consent Form]
*Also, gives permission for HFS, QA Audits and providers to return to your school and re-check your child's sealants.

  • Absolute joy to work with your company! Love the fact that you come back and do "urgent" care on my students! Will recommend to other schools and can't wait to see you next year!!

    - Julie Aderman
    Nurse St. Elmo Elem.