(262) 542-0431

Acknowledgement of Receipt of Privacy Notice

Please provide the patient or guardian's full name.
Please provide patient's date of birth.

Your privacy and the privacy of your protected health inforamtion is important to us.  To provide you with health care, we must share your protected health information. It will be used for treatment, payment, and our health care operations. 

Our Notice of Privacy Practice ("NPP") gives you information about how we may use and disclose your protected health information.  You have the right to review our NPP before signing this Acknowledgement. 

Our privacy practices may change over time.  If we change our NPP, we will provide you with a new copy the next time you receive care. 

You must agree to the Terms & Conditions to submit this form online.
Sign Above
Please provide an electronic signature.
Invalid Input

Conveniently located off I-94 in Waukesha!

1600 Summit Ave, Waukesha, WI 53188

Phone: (262) 542-0431
Fax: (262) 542-0326
info@waukeshafamilydentistry.com

Call for Your Appointment Today!

  • "Knowledgeable professionals who do quality dental work"

    Darlene - Waukesha, WI
    "If you're in search of a good dentist, look no further. Dr. Shoemaker and his team are knowledgeable professionals who do quality dental work. Their main objective is keeping me happy and healthy. I am always greeted with a smile and treated as a friend rather than a patient."

  • "Thank you! Thank you!"

    Jim - Waukesha, WI
    Dr. Gene, Thank you for fixing my teeth. It is nice to be able to chew my dinner now! Thank you! Thank you!

  • "Most caring group of professional people"

    Lynette - Waukesha, WI
    "If anyone is looking for the best dental practice around this area, I can help you with that choice. Dr. Shoemaker and his staff are the most professional, caring group of people I have ever dealt with. Always smiling and efficient, they have given me twenty years of wonderful care."

  • "Everyone in the office is like family"

    Marie - Oconomowoc, WI
    "I love being a patient of Dr. Gilson because everyone in the office is like family. They are very professional and understanding about things that come up, if I have to cancel my appointment. She is truly a wonderful dentist. She is very thorough and makes sure you leave the office happy and not in pain. I would highly recommend her dental office to everyone I know! They are all the best!!"

  • "We look forward to dentist appointments"

    Allie & Jim - Wauwatosa, WI
    I have three children; ages 8 and younger and they also love Dr. Gilson. We look forward to Dentist appointments, which is no small feat for the children. Most recently, she extracted my oldest son's two stubborn teeth and dealing with a tooth extraction on a 7 year old boy, he left with a smile on his face and a mother at ease from Dr. Gilson's gentle approach and kindness towards my son. We are thankful beyond belief to have found her as our family dentist and can not imagine dentistry any other way!