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  • Thank you for your interest in West Brattleboro Family Practice. Please complete this HIPAA secure form in its entirety so that we have a clear understanding of your needs. Once received, we will review your application and connect with you to discuss next steps.
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  • Emergency Contacts

    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.
  • Medical History

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  • Social History

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  • Consents and Agreements

  • No Show & Cancellation Policy

    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 15 minutes early to all appointments. If a patient is 15 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.
  • Please note that a scribe service may be used during medical appointments.

  • Consent for Treatment:

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