(262) 542-0431

HIPPA Authorizations

Authorization to Release Information to Family Members

Many of our patients allow family members such as their spouse, parents, or others to call and request personal information regarding dental treatment.  Under the requirements of HIPPA, we are not allowed to give this information to anyone without the patient's written consent.  If you wish to have your dental information released to family members you must sign this form.  Signing this form will only give consent to release dental information to the family members indicated below.  This consent form will not allow Drs. Shoemaker & Gilson to release any other information to these family members.

You have the right to revoke this consent, in writing, except where we have already made disclosures on your prior consent. 

Please provide the patient or guardian's full name.

I authorize Drs. Shoemaker & Gilson to release my dental information to:

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You must choose one of the authorization options to submit this form.

Authorization to Leave Messages with Household Members/Answering Machine

From time to time it may be necessary for an employee of Drs. Shoemaker & Gilson to leave messages for patients regarding their care.  At no time will a representative discuss your dental circumstances or conditions without your consent.  The purpose of this consent is to obtain your authorization to leave a message with a member of your household or on your answering machine, which may or may not be confidential.  

You have the right to revoke this consent, in writing, except where we have already made disclosures on your prior consent.

You must choose one of the authorization options to submit this form.
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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!