Patient Forms


 Medical History Form

Health Info Consent Form

HIPAA Privacy Policy 

Privacy Acknowledgement



Welcome to the dental office of Dr. Jody Gundler . Thank you for taking time to check out our website. We look forward to meeting you in our office soon and are happy you've chosen us to serve your dental needs.

We have tried to provide information on our website that will help you get to know us and know what to expect for your first visit. For your convenience you can download and complete the required new patient forms to the right. Please bring them with you to your appointment.

Please take a moment to read through our cancellation and billing policies below. If you have any questions or we can help you an in any way, please do not hesitate to call our office at (937) 783-5505.

Cancellation Policy

We understand your time is valuable and do our best to run an efficient practice with as little waiting as possible. Please understand that our time is also valuable and if you must cancel an appointment, please give our office at least 24 hour notice so that another patient may be scheduled at your appointment time. Patients who give less than 24 hours notice on a cancellation more than once may incur a $26.00 charge to their account.

you have dental insurance, please bring your card with you to show the receptionist. If you have double dental insurance, please show both cards. Our office will file insurance claims on your behalf as a service to you. Deductibles and/or co-payments are due at the time of service. The estimated percentage for which you are responsible is also due at the time of service. Our receptionist will contact the insurance company as a service to you so that we may estimate the amount due. You will be responsible for any insurance claims not paid after 60 days.

If you do not have dental insurance, payment is expected at the time of service. If you are an emergency patient, payment is expected prior to service.

Thank you for your patronage!

If you are a new patient to our office, the attached file contains our new patient bundle with forms that will need to be filled out when you arrive at our office. Printing them, filling them out and bringing them with you will allow us to attend to your medical needs more quickly than completing them on your arrival.  Thank you and please call our office if you have any questions at all.

This web site uses files in Adobe Acrobat Portable Document Format (pdf) which require Adobe® Acrobat® Reader for viewing and printing. It is available to download free.