Patient Forms
We are happy to provide our office forms for convenient online secure submission. Questions about which forms you need to fill out? Please call our office and our staff will assist you in preparing for your visit.
New Patient Forms7
Please fill out before your first appointment.
- Health Questionnaire (All new patients, counseling and medical.)
- Consent for Release of Information - Transferring to our office (For requesting old records from another provider.)
- Consent for Release of Information - Transferring out (For sending records to another provider.)
- Consent for Release of Information - School Release (For communication between schools and practice.)
- HIPAA Privacy Policy (Privacy policy for South Royalton Health Center.)
- Patient Care Agreement (Patient Care Agreement for South Royalton Health Center.)
- Patient Care Agreement (18 Years and Older) (Patient Care Agreement for 18 years and older patients at South Royalton Health Center.)
Well Visit Forms5
Save time at your visit! Click on the links below and fill out the developmental screeners and health history updates electronically, it will be sent to our office securely and ready for your visit!
- Annual Health History Update (Parents/guardians please complete at each yearly well visit.)
- Ages and Stages Development Screener (ASQ) (Please complete both the appropriate ASQ and the ASQ-SE for all well visits from 6 months to 4 years.)
- Teen Screener (Teens and young adults please complete at each well visit.)
- Dental Care Risk Assessment (Please complete for all well visits between 6 months and 3 years.)
- MCHAT (Please complete for your 18 month and 2 year well visit.)