Smith

Patient Forms
Before your child's first visit, please complete the new patient forms listed below and bring them with you to the appointment.

To read and/or download our Notice of Privacy Practices, please click here or request a copy when you sign in at the office.
You must have the free Adobe Reader to view these forms. Get Adobe Reader.
New Patients - These forms will be requested prior to your first visit.
Office Policies
Practice Privacy Notice
HIPAA Consent Form
Consent for Treatment Form
Assignment of Benefits/Release of Information
Medical Records
Medical Records Release Form
Office policies and/or forms posted on this webpage may be subject to change from time to time. Please call our office for any current updates to our forms or to ensure that our forms are accurate.
Office Policies
To read and/or download our Notice of Privacy Practices, please click here or request a copy when you sign in at the office.

Before your child's first visit, please complete the new patient forms listed below and bring them with you to the appointment.
You must have the free Adobe Reader to view these forms. Get Adobe Reader.
New Patients
Transfer In
Transfer Out
Medical Records - These forms will be requested prior to your first visit.
Patient Information
New Patient History
Receipt of Notice of Privacy Practices Written Acknowledgement Form
Patient Consent for Use and Disclosure of Protected Health Information
Financial Policy
Parent Resources
Before your child's first visit, please complete the new patient forms listed below and bring them with you to the appointment.

To read and/or download our Notice of Privacy Practices, please click here or request a copy when you sign in at the office.
You must have the free Adobe Reader to view these forms. Get Adobe Reader.
New Patients - These forms will be requested prior to your first visit.
Patient Information
New Patient History
Receipt of Notice of Privacy Practices Written Acknowledgement Form
Patient Consent for Use and Disclosure of Protected Health Information
Financial Policy
Medical Records
Transfer In
Transfer Out
Support Groups
To read and/or download our Notice of Privacy Practices, please click here or request a copy when you sign in at the office.

Before your child's first visit, please complete the new patient forms listed below and bring them with you to the appointment.
You must have the free Adobe Reader to view these forms. Get Adobe Reader.
New Patients
Transfer In
Transfer Out
Medical Records - These forms will be requested prior to your first visit.
Patient Information
New Patient History
Receipt of Notice of Privacy Practices Written Acknowledgement Form
Patient Consent for Use and Disclosure of Protected Health Information
Financial Policy
Diseases & Conditions
Before your child's first visit, please complete the new patient forms listed below and bring them with you to the appointment.

To read and/or download our Notice of Privacy Practices, please click here or request a copy when you sign in at the office.
You must have the free Adobe Reader to view these forms. Get Adobe Reader.
New Patients - These forms will be requested prior to your first visit.
Patient Information
New Patient History
Receipt of Notice of Privacy Practices Written Acknowledgement Form
Patient Consent for Use and Disclosure of Protected Health Information
Financial Policy
Medical Records
Transfer In
Transfer Out
Multimedia Library
To read and/or download our Notice of Privacy Practices, please click here or request a copy when you sign in at the office.

Before your child's first visit, please complete the new patient forms listed below and bring them with you to the appointment.
You must have the free Adobe Reader to view these forms. Get Adobe Reader.
New Patients
Transfer In
Transfer Out
Medical Records - These forms will be requested prior to your first visit.
Patient Information
New Patient History
Receipt of Notice of Privacy Practices Written Acknowledgement Form
Patient Consent for Use and Disclosure of Protected Health Information
Financial Policy
Immunizations
Before your child's first visit, please complete the new patient forms listed below and bring them with you to the appointment.

To read and/or download our Notice of Privacy Practices, please click here or request a copy when you sign in at the office.
You must have the free Adobe Reader to view these forms. Get Adobe Reader.
New Patients - These forms will be requested prior to your first visit.
Patient Information
New Patient History
Receipt of Notice of Privacy Practices Written Acknowledgement Form
Patient Consent for Use and Disclosure of Protected Health Information
Financial Policy
Medical Records
Transfer In
Transfer Out
Billing
To read and/or download our Notice of Privacy Practices, please click here or request a copy when you sign in at the office.

Before your child's first visit, please complete the new patient forms listed below and bring them with you to the appointment.
You must have the free Adobe Reader to view these forms. Get Adobe Reader.
New Patients
Transfer In
Transfer Out
Medical Records - These forms will be requested prior to your first visit.
Patient Information
New Patient History
Receipt of Notice of Privacy Practices Written Acknowledgement Form
Patient Consent for Use and Disclosure of Protected Health Information
Financial Policy
Monthly Tips
Before your child's first visit, please complete the new patient forms listed below and bring them with you to the appointment.

To read and/or download our Notice of Privacy Practices, please click here or request a copy when you sign in at the office.
You must have the free Adobe Reader to view these forms. Get Adobe Reader.
New Patients - These forms will be requested prior to your first visit.
Patient Information
New Patient History
Receipt of Notice of Privacy Practices Written Acknowledgement Form
Patient Consent for Use and Disclosure of Protected Health Information
Financial Policy
Medical Records
Transfer In
Transfer Out
Useful Links
To read and/or download our Notice of Privacy Practices, please click here or request a copy when you sign in at the office.

Before your child's first visit, please complete the new patient forms listed below and bring them with you to the appointment.
You must have the free Adobe Reader to view these forms. Get Adobe Reader.
New Patients
Transfer In
Transfer Out
Medical Records - These forms will be requested prior to your first visit.
Patient Information
New Patient History
Receipt of Notice of Privacy Practices Written Acknowledgement Form
Patient Consent for Use and Disclosure of Protected Health Information
Financial Policy