Paperwork conveniently at your fingertips.
Important Notice
Do NOT email completed patient forms. Patient information should NEVER be emailed.
Adobe Acrobat
You will need a PDF reader, such as Adobe Acrobat Reader, installed on your computer to fill out forms.
Patient Forms
Important Notice
Do NOT email completed patient forms. Patient information should NEVER be emailed.
Adobe Acrobat
You will need a PDF reader, such as Adobe Acrobat Reader, installed on your computer to fill out forms.
First Appointment Form
First Appointment Form
Before your child’s First Visit to Dr. Gjebre, let’s get some basic paperwork out of the way.
Please complete & 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.
Privacy Practices
Privacy Practices
Please download our Privacy Practices information.
PRINT & SIGN the Acknowledgment Receipt of Privacy Practices form. Bring it with you to your first appointment.
(Read)
(Print & Sign)
If you have any questions or concerns, please don’t hesitate to Contact us today.
Payment 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.
Payment 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.