New Patient App

**Please note that although we are accepting applications for new patients, appointments may be postponed due to COVID-19.**
New Patient Application Request

We thank you for your interest in becoming a new patient with West Brattleboro Family Practice. We ask that you provide the requested information below so we are able to determine if you will benefit by becoming a patient and for a smooth transition if you are accepted. This form is HIPAA secure and all the requested information will be used in your medical chart.
Help us get to know you!

As a Private Practice, we reserve the right to request an application process. Not all information obtained on this form will be used to determine acceptance. All information will be used to complete your medical chart upon acceptance.
What services are you interested in? *
Full Name *

First Name Middle Name Last Name Suffix
Date of Birth *
Social Security Number (Remember, this is a HIPAA secure application) *
SS# is used to verify insurance and billing purposes
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
Work Number

Area Code Phone Number
What is you preferred phone number? *

Home Cell Work None
If the patient is under 18 years of age, please provide the following information.
E-mail *
example@example.com
Pharmacy (name and location) *
Please indicate primary pharmacy and location
Employment Status *

Full time Part Time Retired Unemployed Self- Employed Student- see below Disabled
Name of Employer or School
Preferred Language *

English French Spanish
Marital Status *

Married Single
What is your current gender identity? (check ALL that apply) *

Male Female Transgender Male / Transman / FTM Transgender Female / Transwoman / MTF Gender Queer Decline to answer
What sex were you assigned at birth? (check one) *

Male Female Decline to answer
Do you identify as: (check all that apply) *

Straight Gay Lesbian Bisexual Decline to answer
Race: *

American Indian of Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
Ethnicity *

Hispanic or Latino Non-Hispanic or Latino Prefer not to indicate
Who is your current / previous Primary Care Provider? *
When was your last annual exam? *
Current Primary Care Provider / Office. *
This will help us obtain basic information for your first appointment.
Insurance information

Please provide all insurance information
Name of Primary Insurance *
Insurance ID #: *
Group#:
Insurance effective date
When did your insurance start?
Subscriber Name & Relation:
Who is the insurance listed under? yourself, spouse, parent (Medicare is self)
Subscriber's Date of Birth (If different from the patient)
IF you are able to include a photo of your insurance card, please do so here.

Browse Files

Cancel of
Name of Secondary Insurance
If you have a secondary insurance, please list it here
Insurance ID #:
Subscriber Name & Relation:
Group#:
IF you are able to include a photo of your insurance card, please do so here.

Browse Files

Cancel of
Emergency Contact

Please provide the below information for the person you'd like us to call in case of an emergency. It is very important for our office to have this on file.
Name of Primary Emergency Contact *
In the event of an emergency, who would you like us to call?
Phone number for Primary Emergency Contact *
Relationship to Emergency Contact *
Do you give us permission to talk with your primary emergency contact person about your medical care outside of an emergency? *

Yes No
Name of Secondary Emergency Contact *
If we are unable to reach your primary Emergency Contact, in the event of an emergency, who should we contact second?
Phone number for Secondary Emergency Contact *
Do you give us permission to talk with your secondary emergency contact person about your medical care outside of an emergency? *

Yes No
Would you like to give us permission to speak to any other individuals about your care? If yes, please list their names, phone number and relation.
Spouse, Partner, Children, Friend etc.
Medical History

Please provide answers for all questions regarding your previous medical history
List all medical conditions/problems you have -EVER- been diagnosed with. *
If you have no medical conditions or problems, please write none
MEDICATION ALLERGIES: *
If you have no allergies, please write none
List past surgeries and hospitalizations: *
If you have no past surgeries or hospitalizations, please write none
List all supplements, herbs and medications: (include name, dosage and instructions) *
If you don't take any medications, supplements or herbs, please write none.
List all specialist you are currently seeing and the reason *
If you don't see any specialists, please write none
Social History
Do you participate in any of the following: *

Current Cigarette smoking Cigars Former Cigarette smoker Vaping Chewing Tobacco Cannabis Alcohol Consumption Recreational Substances None
Do any of the below family members have any serious health conditions ? -------------- --Include-- Mother, Father, Maternal/Paternal Grandparents, Siblings & Children.
Example: Cancer, Stroke, Glaucoma, Diabetes, Seizures, Bleeding disorders, kidney disease, thyroid disease, mental illness, osteoporosis, high blood pressure, heart disease .
Consents and Agreements
Accurate Information Given *

By checking this box, I certify that the information I have given is complete and accurate to the best of my knowledge. I understand that failure to provide accurate information may result in termination of services at West Brattleboro Family Practice and report of the failure to the Federal Government.
No Show & Cancellation Agreement:

We understand that situations arise in which you must cancel your appointment. We ask that if you must cancel your appointment that you provide more than 24 hours’ notice. We kindly ask that all patients arrive 10 minutes early to all appointments. If a patient is 10 minutes or more past their scheduled time (20 minutes including early arrival) we cannot guarantee that you will be seen and you may be asked to reschedule. Office appointments cancelled with less than 24 hours notification will be subject to a $50.00 cancellation fee. Patients who do not show up for their appointment without a call to cancel an office appointment or procedure appointment will be considered as NO SHOW. Patients will also be subject to a $50.00 fee for No Show of their scheduled appointment. Please note – your insurance company will not be billed for this fee. The Cancellation and No Show fees are the sole responsibility of the patient and must be paid in full before the patient’s next appointment. We understand that occasionally special and unavoidable circumstances may cause you to have to cancel within 24hours. Fees in this instance may be waived but only with management approval. Our practice firmly believes that a good physician/patient relationship is based upon understanding, trust and good communication. We thank you in advance for your kind consideration.
No Show & Cancellation Agreement: *

I acknowledge that I have read and been informed about the requirements and expectations of the No Show & Cancellation Policy provided and required by West Brattleboro Family Practice. I have received a copy of the policy and agree to abide by the policy guidelines.
Payment on the day of services:We kindly ask that all patients pay ON THE DAY SERVICES ARE RENDERED for any deductibles, co-insurance amounts, co-payment amounts, out-of-pocket expenses and/or non-covered services that may apply. *

I am aware of the 'Payment on same day" request and will come to my appointment prepared.
Consent for Treatment:
I hereby give my consent for West Brattleboro Family Practice to conduct treatment and to receive payment for health care services. I have received a copy of this office’s Notice of Privacy Practices and I understand that this office may disclose my health information for the purposes of providing and coordinating treatment, conducting health care operations, providing health information, and obtaining payment. I understand I have the right to withdraw this consent at any time, and that doing so will not affect any actions which were taken by West Brattleboro Family Practice before I withdrew this consent. If you'd would like a copy of the Notice Of Privacy Practices, please pick one up from the office.

I have read the 'Consent for Treatment' and give my consent for treatment.
Signature *

Clear
Date signed *
Please note that this office uses a scrib/scribe services during appointments.
West Brattleboro Family Practice

Craig E. Goldberg, D.O. | Claudia E. Matta, PA-C

P.O. BOX 2388 1027 WESTERN AVE. • BRATTLEBORO, VT • 05303

Phone: (802) 254-4545 • Fax: (888) 491-1581
Should be Empty:

**Please note that although we are accepting applications for new patients, appointments may be postponed due to COVID-19.**

New Patient Application Request

Help us get to know you!

Insurance information

Emergency Contact

Medical History

Social History

Consents and Agreements

No Show & Cancellation Agreement:

Consent for Treatment:

Please note that although we are accepting applications for new patients, appointments may be postponed due to COVID-19.