Patient Forms

Patient Forms | Jerry Q. Gilder DDS

We want to welcome you to the office of Jerry Q. Gilder DDS!

We are glad that you are interested in becoming a patient of Dr. Jerry Gilder’s Hattiesburg, MS dental practice. New patients are always welcome here. You can count on our friendly, experienced team to always provide the highest standard of dental care in a clean, state-of-the art environment. Your comfort is our top priority.

For your convenience you will find below a list of the most common patient forms used at our office. Take a moment to print and complete them prior to your next appointment.


Patient Registration

Financial Agreement

Privacy Consent 

Privacy Policy


As a recipient of Federal financial assistance, Jerry Q. Gilder, DDS, does not exclude, deny benefits to, or otherwise discriminate against any person on the basis of race, color, national origin, disability, or age in admission to, participation in, or receipt of the services and benefits under any of its programs and activities, whether carried out by Dr. Gilder directly or through a contractor or any other entity with which Dr. Gilder arranges to carry out its programs and activities.