Request Appointment

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

    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
    AMPM

    Treatment Options
    Regular CheckupFirst Dentist VisitEmergency/UrgentOther

    Do you have Dental Insurance?
    YesNo

    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:

    aapd fapd SCL - Logo PCDA - Logo HCDA - Logo AAO - Web Blue ADA - Web Florida Dental Association
    © A Safari Dental 2021