New Patient Forms:
Please click on the following form titles, print the forms, and then complete. Bring the completed forms with you to your first appointment.
Adult Patient Information Form
Child Patient Information Form
Financial Policy updated 9-19-2022 updated
Patient agreement insurance coverage 9.14.22
Medical Record Release Please fill out this form completely. Incomplete forms may delay or prevent us from receiving medical records from your previous provider.
Medicare Wellness Questionnaire
Auth for Evaluation and/or Treatment of a Minor Child w/o Parent or Guardian
Patient Satisfaction Survey You can fax your anonymous response to C. Smith Clinic Office Manager at 360-413-8615
or mail your response to Pioneer Family Practice ATTN C. Smith at 5130 Corporate Center Ct. SE Lacey WA 98503
Please also visit Healthgrades.com and Vitals.com to leave reviews of your providers visit.
Development Assessment Questionnaires for Children:
Please click on the following form titles, print the forms, and then complete. Bring the completed forms with you to your child’s appointment.