Request Appointment

    Are you a current or former patient at our office? (required)


    Child's First Name (required)

    Last Name (required)

    Date of Birth (required)

    Parent / Guardian Name (required)

    Email (required)

    Phone (required)

    Preferred Contact

    Preferred Month

    Preferred Time


    Treatment Options

    Regular CheckupFirst Dentist VisitEmergency/UrgentOther

    Do you have Dental Insurance?


    If "yes", who is your Dental Insurance Provider?

    (Our office gladly accepts children with no dental insurance)

    Additional Notes


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    Professional Associations

    A Safari Dental is an active member of the following professional associations:

    aapdfapdSCL - LogoPCDA - LogoHCDA - LogoAAO - Web BlueADA - WebFlorida Dental Association

    A Safari Dental is a proud supporter of the 1Voice Foundation for pediatric cancer.
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