New Patients

New Patient Form

If you are a new patient, save some time by filling out our standard form online below prior to your office appointment visit, or click here to print the paperwork instead. Also, here is our HIPPA policy for you to reference. Dr. Smielewski strives to improve the overall health of our patients by focusing on preventing, diagnosing, and treating conditions associated with your feet. Please use review our website to learn more about podiatric problems and treatments available. 

Patient Information:

If Patient Is A Minor:

Only complete the following if the patient is under the age of 18.

HIPPA Privacy Policy:

I have been notified about the HIPAA privacy rules regarding my personal, health, and medical information. This information is available here. I may request a copy from the office. My signature acknowledges acceptance of the privacy policies.

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