Patient Registration

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Dr. Smith periodically sends updates via email

**Please note that we are not contracted with any Insurance at this time. We are not a Medicare provider and are not contracted with any State Funded policies.

Consent to treat: I understand by signing below I consent to medical treatment performed by Stephen L Smith, MD and his staff. I understand that no guarantee has been made regarding results of such treatment.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.