Forms / Downloads

Downloadable forms in PDF and MS Word format are available below. 

If you need to make a payment. Please select your payment option and click "Buy Now". 

Cash Payment Price





We are now serving patients in Indiana. You can find the necessary PDF forms at the links below. 

Consent Form - Indiana
Consent Form - Indiana (Spanish)
Whats Your Cost - Indiana
Whats Your Cost - Indiana (Spanish)



Click Here for the Dental Safari Online Consent Form

  • The Safari Dental was a great experience for our Head Start children. The Dentist and Assistant were so kind and it made the children feel comfortable and relaxed. The dental van returned and treated 17 children who had urgent and restorative care. The parents were thankful and sang their praise. Thank You, again.

    - Joyce Overton
    Health & Nutrition Specialist Western Egyptian Head Start