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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.

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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.

payments options

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.

payments options