How to Complete Our
First Appointment Form
You must have
Acrobat Reader
installed on your computer.
Click the link to Open our
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
Read the information, then
Open, Print, and Sign our
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.
