Patient Forms and Information

New Patient Forms

Thank you for choosing Dr. Gutenberg and Associates Pediatric Dentistry to be your child’s dental care provider! Please complete the following forms prior to your child’s/children’s first scheduled dental appointment.

*Dr. Gutenberg and Associates Pediatric Dentistry Health History Contact Information and Financial Responsibility Payment Method / Dental Insurance Policy

– Notice of Privacy –

Acknowledgment of Receipt of Notice of Privacy Acts **Authorization for Agent to Consent to Dental Treatment of a Minor ***Infant Frenectomy Intake Form

*One form is required per child.

**Consent form only needs to be completed if someone other than the legal parent/guardian is bringing the child/children to ANY type of dental appointment.

***Only to be completed if your infant is scheduled for a consultation for a tongue/lip tie.

Returning Patient Forms

Dr. Gutenberg and Associates Pediatric Dentistry 6 Month Informational Update Form

We kindly ask that all returning patients please complete this informational update form prior to every six month examination appointment. One form is required per child.

Referring Provider Forms

We kindly ask that all referring providers please complete this form digitally prior to referring patients to Dr. Gutenberg and Associates Pediatric Dentistry. This form aids our office in understanding the dental needs of the patient and what the referring provider is requesting we evaluate.

*Dr. Gutenberg and Associates Pediatric Dentistry Referral Form

*Referral form can be printed, completed, and provided to the referring patient, if needed. To print, access the blank PDF by clicking the above link, click “Start Filling”, scroll to the bottom of the form and click “Preview PDF”

Insurances

Dr. Gutenberg and Associates Pediatric Dentistry gladly accepts most insurances. We are also happy to provide services to those that are uninsured, underinsured, or have insurance that is out-of-network with our offices. Call Dr. Gutenberg and Associates Pediatric Dentistry today for details.

Payment Options and Financing

For your convenience, we accept payments made with cash, Visa, MasterCard, and Discover.

Financing is also available through CareCredit. With CareCredit, you pay no up-front costs, no pre-payment penalties and no fees. Plus, CareCredit is a revolving credit line for additional care or add-on charges, without the need to re-apply. Use CareCredit’s Payment Calculator to compare plans and get an estimate of what your monthly payment will be.

It only takes a few minutes to apply for CareCredit and you may receive an online decision in seconds! Apply now or see our staff for more details.

Palm Springs Location

490 S. Farrell Drive, Suite C-101
Palm Springs, CA, 92262

(760) 320-7621

Yucca Valley Location

7144 Airway Avenue,
Yucca Valley, CA 92284