How to Complete Our
First Appointment Form

You must have Acrobat Reader
installed on your computer.

Click the link to Open our

First Appointment FormAcknowledgement Form

Type in your information.

PRINT THE FORM

Bring a completed copy
to your first appointment.

DO NOT EMAIL THE COMPLETED FORM 
Patient information should never be emailed

Privacy Information

Click the link to Open our

Notice of Privacy PracticesAcknowledgement Form

Read the information, then
Open, Print, and Sign our

Acknowledgement ReceiptAcknowledgement Form

Credit cards, cash, and checks accepted

Patient Forms

Downloadable Patient Forms

Before your child’s First Visit to Dr. Gjebre, let’s get some basic paperwork out of the way.

First Appointment Form

Please COMPLETE and then PRINT the First Appointment Form, then bring a copy with you to your appointment.  Please DO NOT EMAIL the completed form, as it contains sensitive background information.  (Adobe Reader required.)

Privacy Practices

Please download our Privacy Practices information above, then PRINT and SIGN the Acknowledgement Receipt of Privacy Practices form. Bring it with you to your first appointment. (Adobe Reader required.)

If you have any questions or concerns, please don’t hesitate to Contact us today.

Financial Information

If you are self-pay or have dental insurance that has a deductible, copays, and/or frequency limitations, payment is due at the time services are rendered.

We accept cash, check, Visa, and MasterCard.

Contact Dr. Gjebre today to learn more. 

 

 

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