New Patient App

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.
What services are you interested in?*
Full Name*

First NameMiddle NameLast Name
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

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Work Number

Area CodePhone Number
Please click your preferred phone number*

HomeCellWorkNone
If the patient is under 18 years of age, please provide the name of the financially responsible party with their address, phone number and patient's relationship to the guarantor in the box below
Name of Employer or School
Employment Status
Preferred Language - if other than English:
Ethnicity*

Hispanic or LatinoNon-Hispanic or LatinoPrefer not to indicate
What sex were you assigned at birth?*

MaleFemale
Please describe your gender identity if different from your birth sex above
Insurance Information
Name of Primary Insurance*
Insurance Member #:
Group #:
Insurance Effective Date
When did your insurance start?
Subscriber Name & Relationship to Patient:
Who is the insurance listed under if other than self?
Subscriber's Date of Birth
IF you are able to include a photo of your insurance card, please do so here.

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Name of Secondary Insurance
If you have a secondary insurance, please list it here
Insurance Member ID #:
Group #:
Insurance Effective Date
When did your insurance start?
Subscriber Name & Relationship to Patient
Who is the insurance listed under?
Subscriber's Date of Birth
IF you are able to include a photo of your insurance card, please do so here.

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Cancelof
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.
Primary Emergency Contact*
Primary Emergency Contact Phone*
Your 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?*

YesNo
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?
Secondary Emergency Contact Phone *
Your relationship to Emergency Contact*
Do you give us permission to talk with your secondary emergency contact person about your medical care outside of an emergency?*

YesNo
We do not share your health information without your permission with anyone unless they are part of the healthcare system and are directly involved in your care. You may list anyone in the field below that you would either like us to share information with or with whom you specifically do not want information shared.
Medical History

Please provide answers for all questions regarding your previous medical history
Current Primary Care Clinician / Office*
This will help us obtain basic information for your first appointment.
Date of last annual exam*
Name and location of pharmacy you prefer to use*
List all medical conditions/problems you have EVER had diagnosed *
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 specialists you are currently seeing and the reason why.*
If you don't see any specialists, please write none
Social History

Do you participate in any of the following:
Cigarette smokerCigar smokerVapingChewing TobaccoCannabisAlcohol ConsumptionOther
What is your level of use for each of the above options you have checked? Please include former use level as well.
FAMILY MEDICAL HISTORY. Please indicate serious illnesses affecting your Mother, Father, Maternal or 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 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 indicate acknowledgement*

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 and agree to abide by the agreement guidelines.
PAYMENT IS DUE ON THE DAY SERVICES ARE RENDEDERED. We kindly ask that all patients pay any deductibles, co-insurance amounts, co-payment amounts, out-of-pocket expenses and/or non-covered services that may apply on the same day as services are provided.*

I am aware of the 'Payment on same day" request and will come to my appointment prepared.
Please note that a scribe service may be used during medical appointments.
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 understand that this office may disclose my health information for the purpose of providing and coordinating treatment and to your insurance carrier in order to obtain payment. I understand that 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.

I have read and give my Consent for Treatment
Signature*

Clear
Date signed*
Should be Empty: