Forms

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

 

Family Health Questionnaire

 

Financial Policy and Agreement

 

Records Release  Please fill out this form completely. Incomplete forms may delay or prevent us from receiving medical records from your previous provider.

 

Patient Portal Sign up

 

Miscellaneous Forms:

 

Change of Information Form

 

Notice of Privacy Practices

 

Records Release

 

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 5301 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.

 

ASQ 9 Month Questionnaire

 

ASQ 18 month Questionnaire

 

MCHAT-R (18 Months)

 

ASQ 24 Month Questionnaire