Patient Forms

Attached, please find important patient forms to be completed by a parent/guardian before each child's initial visit.


















The downloadable files contain 

  • Patient Registration 

  • Patient Health History

  • Medication and Physician Registry

  • General Consent for Treatment

  • Confirmation Policy

  • Temporary Guardianship Agreement 

  • Notice of Privacy Practices

  • Patient Acknowledgement and Consent of Privacy Practices

Text Only Patient Registration Forms

New Patient Forms PDF

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Kerri S. Gustafson, DDS, PLLC complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age (exception - we are a pediatric specialist), disability, or sex. 
Language assistance services are available. 

© 2020 by Kerri Gustafson, DDS, PLLC.

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