You
can register
online, or you can print out the blank forms and fill them out by hand.
Click here to go to our secure online registration form. (Please note that online registration is currently only available for adult patients).
The New Patient Forms are in Adobe Acrobat (PDF) format. If you do not have Acrobat Reader, get a free copy by clicking on the link below.
The other forms do not require the reader and will open in a new browser window.
Please print the appropriate New Patient Form below and the Authorization for Release of Information, fill them out, and bring them with you for your appointment. Also, after reading the Notice of Privacy Practices, print the Acknowledgement form, sign it, and bring it in, too.
Adult New Patient Form (Acrobat
PDF form)
Child
(under 18) New Patient Form (Acrobat
PDF form)
Authorization for Release of Information (web page)
Acknowledgement of Receipt of Notice of Privacy Practices (web page)
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© Copyright 2004- Dental WebSmith, Inc. and Reynoldsburg Family Dental - Michael J. Smith, D.D.S. All rights reserved. Disclaimer: The information provided within is intended to help you better understand dental conditions and procedures. It is not meant to serve as delivery of medical or dental care. If you have specific questions or concerns, contact your health care provider.
