dental safari forms

Click on the Appropriate Form Below to Complete Your Child’s Registration!

Illinois dental consent form, illinois dental consent form (spanish), indiana dental consent form, indiana dental consent form (spanish), 7562 old route 13 marion, il 62959, phone: 618-993-8333 fax: 618-933-8335, email: [email protected], website: http://www.dentalsafaricompany.com/.

Dental Safari’s mobile dental office is a self-contained, fully-functioning dental operatory where children receive the same professional services as those performed in a traditional office.

Equipped with the latest dental technology, our dentists are more efficient and are able to perform more dentistry per appointment. In our on-site, kid-friendly mobile dental office, we specialize in on-location Quality Examinations, Cleanings, Fluoride Treatments, and placement of Sealants (as needed).

Currently partnering with 100 schools, we bring the dental office to you! Simply make an appointment, parents/guardians check their kid out of class, and walk to the dental office at school!!

Contact us today or visit our website for more information!

“This is a great opportunity for our students. The staff was great with kids and we only heard good things after their exams.”

– Ryan McClellan Principal, Evansville Elem.

Dental Consent Form

School information, child's information, parent/guardian information, payment information.

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 (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.

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: [email protected]

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

Please send a photo of both sides of your insurance card to: [email protected]

HEALTH HISTORY

Form completion.

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 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.

By clicking the accept button below, I agree that the signature I have drawn above will be the electronic representation of my signature for all purposes when I use them on online documents and forms - just the same as a pen-and-paper signature.

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• 618.993.8333
• contact @ DentalSafariCompany.com
• 7562 Old Rt 13, Marion, IL 62959

Welcome to Dental Safari Company

Founded by Dr. Melissa Morley, Dental Safari Company is a professional, mobile-dentistry corporation.

Click Here for the Dental Safari Online Consent Forms

Every child is eligible.

Whether you pay cash, use private insurance, are on the state of Illinois medical card, or are eligible for grant coverage (children on free or reduced lunch programs), every single child may be seen. Simply fill out our consent form given to you by your school.   Or, if you have misplaced your form, you can simply click on the FORMS / DOWNLOADS link (above) on this website and download another one.

We specialize in on-location Examinations, Cleanings, Fluoride Treatments, and placement of Sealants (as needed) . In addition, our company uniquely offers follow-up surgical treatment (if needed) and in-class dental education instruction given by professionals.

We protect your privacy!

Dental Safari complies with all HIPPA regulations.

Download HIPPA Privacy

Dental Safari Brochure!

Download the latest Dental Safari informational brochure

Download Brochure

This is a great opportunity for our students. The staff was great with kids and we only heard good things after their exams. - Ryan McClellan Principal Evansville Elem.

• Dr Melissa Morley
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Pediatric Dentistry

Dental Safari’s mobile dental office is a self-contained, fully-functioning dental operatory where children receive the same professional services as those performed in a traditional office. Because we bring our office to your child’s school, children need only to step out of class to access dental care.

• Schools Love Us: Children spend minimal amount of time outside of class.
• Parents Love Us: The dentist treating their child can be found at their child’s school.
• Kids Love Us: Our fun and inviting office environment helps to puts children at ease while receiving dental care.

Services We Offer

Regular cleanings help keep gums healthy and teeth cavity-free. A dental cleaning includes removal of tartar and plaque and polishing of the teeth to remove stains and prevent further buildup of plaque.

Dental sealants are made of a safe resin material which is applied to the surfaces of teeth (commonly permanent molars) to prevent cavities. The sealant material fills in the crevices of a tooth and “seals” off the tooth from cavity-causing agents like food and plaque. The teeth are prepared for the sealant application and the sealant is painted directly onto the chewing surface of each tooth and then hardens. Sealants are applied in one visit.

Fluoride is a natural substance that helps strengthen teeth and prevent decay. Fluoride treatments are administered at this office as an important component of pediatric dental treatment. The fluoride is applied to the teeth in a gel, foam, or varnish form.

Silver Diamine Fluoride (SDF) is a caries arresting topical medication that stops the spread of decay for a period of time.

If your child is found to have urgent dental needs following examination, we will provide you with contact information of local Dentists that are accepting new patients. However, The Dental Safari Company does not just provide an examination and move on. If a child does have urgent dental needs, they can be scheduled for follow-up dental care by us.

Preventing dental disease is dependent upon good daily habits. Our professionals will visit classrooms and educate students on healthy dental lifestyles that will benefit them throughout the year until our next visit.

The Importance of Early Dental Care

Your child's first dental visit is an important milestone.

Collinsville Kahoks

Collinsville Community Unit School District 10

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CMS Families: Sign Up for April 1 Dental Safari Exams

• Departments

• Carriel Junior High School
• Fulton Junior High School
• Evans Elementary School
• Hinchcliffe Elementary School
• Kampmeyer Elementary School
• Moye Elementary School
• Schaefer Elementary School

Achieving Excellence

• District Personnel
• Registration
• School Board
• Superintendent
• Pre-K Early Learning Center
• Safety and Security
• Before & After Care
• Food Service

Health Services

• Library & Media
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Page Navigation

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Dental Safari

• Immunization Requirements
• Life Threatening Allergy Forms
• ALL 6th, 7th & 8th Grade Students
• ALL STUDENTS - NEW AND RETURNING
• Kindergarten Students
• New Students (from out of state)
• Pre-Kindergarten Students
• 2nd Grade Students
• Registration Required Forms
• School Wellness Plan
• Sports Participation Required Forms
• Staff CPR Training
• State of Illinois Certificate of Child Health Examination
• Vision Exam Forms
• School Medication Authorization Form
• IL Certificate of Religious Exemption
• O'Fallon C C School District 90

Dental Safari will be at O'Fallon District 90 in Mar/Apr. Please complete the attached form and return to your school nurse as soon as possible.

Safari Dental Brochure

Dental safari consent form, dental safari what is your cost?.

Safari Dental Online Consent Form

Address 118 East Washington Street, O'Fallon, IL 62269

Phone (618) 632-3666

Fax (618) 632-7864

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Celebrate Healthy Smiles

Establishing your child’s oral health foundation has never been easier.

Take the guesswork out of your child’s dental hygiene routine and help your child’s smile shine brighter than ever before. When you become part of our family at Kids Dental Safari & Braces in Las Vegas you will:

• Feel confident about your child’s oral health foundation
• Ensure their teeth, gums, & jaw are developing properly
• Rest assured serious dental issues are avoided by early detection
• Breathe with relief knowing your child’s smile is healthier and happier

Dentistry Designed For Your Child

Child dental care, comfort - sedation dentistry, special needs dentistry, dental emergencies, orthodontics, new patients.

Schedule An Appointment Today

Let's Create Healthy Habits & Smiles Together

Our dedicated team of dentists and hygienists are eager to work with your child to ensure they develop good oral hygiene habits and understand its role on overall health.  Their journey towards a healthy, brilliant smile, is as easy as 1, 2, 3…

Schedule An Appointment

Our front office staff is exceptional and can gladly assist you with scheduling your child’s appointment with ease.

Clean & Treat

Have your child seen by one of the best Pediatric Dentists in Las Vegas for a thorough exam and deep cleaning.

Smile Healthier & Happier

Leave our office relieved knowing that your child has a happier and healthier smile.

Let’s get your kids on track. Get started today by requesting an appointment. 

Our Pediatric Dentist

Dr. Waggoner DDS

Founder, Pediatric Dentist

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Marella Tagatac DDS

Pediatric Dentist

Let's Connect

Enjoy our Kids’ Dental Safari and Braces located near the University District and Paradise McLeod Park. We are in the shopping plaza in between Tropicana Avenue and East Harmon Avenue. Contact our Las Vegas pediatric dental office today to get your kids oral health on the right track.

(702) 786-6684

2381 B. Renaissance Dr. Las Vegas, NV 89119

Dental Safari

We're Wild About Your Child's Smile

Let Us Guide Your Child Through an Exciting Dental Journey!

Preventative Care

6 -month hygiene appointment includes exam, prophy, flossing, ...

Restorative Dentistry

Cavities happen and when they do we offer both...

Emergency Treatment

When an emergency arises and they always do, we welcome...

Our office uses digital radiographs emitting low...

• Dental Safari is located in the Crown Point Plaza near Mellow Mushroom.
• We are in network with all Dental PPOs and accept Medicaid, Peachstate, Wellcare, Envole, Caresource, and Amerigroup insurances.
• We treat up to age 18.
• Cash, debit and credit cards ( Visa, Discover and MasterCard only) are accepted for out of pocket payment.
• A parent or guardian is encouraged to accompany the child during the cleaning, as only the patient is permitted in the room during treatment.
• Appointments are preferred but walk-ins and same day emergencies are welcomed.
• *** New Patient Forms are available HERE ***
• *** Returning Patient Forms HERE ***

Meet The Dentist

Dr. Natasha Wilson Gates

A native of Decatur, GA, Dr. Natasha W. Gates graduated from Southwest DeKalb High School … Go Panthers!! She obtained her Bachelor of Science in Biochemistry from Xavier University of Louisiana and dental degree at the University of Tennessee Health Science Center in Memphis, Tennessee. After practicing in Tennessee and Virginia, Dr. Gates is delighted to return home to practice in the community she loves.

Dr. W. Gates is a member of the American Dental Association (ADA), National Dental Association (NDA) and the Georgia Dental Association (GDA) and attends numerous continuing education courses to remain current on the fast-changing world of dentistry. In her spare time Dr. Natasha W Gates enjoys cycling, roller skating, travel, leisure reading and trying out new restaurants with her husband and child. 

Our Location

Dental Safari is conveniently located near the Mellow Mushroom.

1990 Main Street East Suite E Snellville, GA 30078

Phone & Fax

(404) 924 7428 1 (800) 315 1512

[email protected]

Opening Hours

Send us a message below or call us at: (404) 924-7428

Important Announcement

• Dental Clinic of European Medical Center
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• 8 (495) 127-52-6...
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• Ulitsa Shchepkina, 35 Moscow , Moscow City 121099 (map)

Moscow Maps and Orientation

(moscow, central federal district, russia), maps and orientation of the city.

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