Below we have provided forms for you to fill out for your upcoming visit. Please click on the forms that we have asked you to complete. Once you have completed the forms, you may print them and mail them to us or download the PDF and email it to us at documents@wrfpvt.com. This is a secure email and will protect your confidential medical information. Please include your name and date of birth in your e-mail.
We have also provided advance directives forms below. You can read more about advance directives here.
If you have any problems, please contact us at 802-295-6132.
Asthma Control Test Forms
Children 4 to 11 years of age
Children 12 to 17 years of age
Adults
Ages & Stages Developmental Questionnaires
Annual Wellness Questionnaire
The Annual Wellness Questionnaire form should be completed by Medicare patients and adults 65 and older prior to a yearly wellness exam
Patient Health Questionnaire
The Patient Health Questionnaire form should be completed by adults 64 years of age or younger prior to a yearly wellness exam, diabetes visit or asthma check-up
Attention-Deficit /Hyperactivity Disorder Questionnaires
Medical Release Form
New Patient Intake Form – Pediatric Only
Hippa
Advance Directive Forms
NH: Free New Hampshire Advance Directive Form (Medical POA + Living Will) | PDF (advancedirectives.com)
The Dartmouth Dementia Directive: An advance care document for people concerned about developing Alzheimer’s disease or another dementia
Bill Pay Form
We accept online payments through this form.