(262) 542-0431

Patient Registration Form

Patient Information

Please provide the patient's name.
Invalid Input
Please provide a valid date of birth in the following format (mm/dd/yyyy)
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input

Employment Information

Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input

Other Information

Invalid Input
Invalid Input
Invalid Input
Invalid Input

Payment Information

Please provide the name of the person responsible for the account.
Please provide a method of payment.

Dental Insurance: 1st Coverage

Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input

Dental Insurance: 2nd Coverage

Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input
Invalid Input

Consent Statements

I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care.

I consent to the dentist's use and disclosure of my records (or my child's records) to carry out treatment, to obtain payment, and for those activities and health care operations that are related to treatment or payment.

I authorize payment directly to the dentist or dental group of insurance benefits otherwise payable to me.  I understand that my dental care insurance carrier or payor of my dental benefits may pay less than the actual bill for services, and that I am financially responsible for payment in full of all accounts.  

I agree to be responsible for payment of services not paid by my dental care payor. 

You must check the consent box 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!