Patient Portal
30 West Main St, Richmond, VT 05477
Monday-Friday 8 to 5, Saturday 9-Noon
Telephone: 802-434-4123

Forms

For new and existing patients, there are several forms we may require to have on file to maintain accurate records for you.  These forms are provided in this section to save you time at the front desk when you arrive for your appointment.

Please fill out the following 2 forms if you haven't before
  • SEEK Questionnaire
  • Initial History Questionaire


  • Age Based Questionnaires & Educational Materials:
    WCC Milestone Questionnaire Educational handout(s)

    INFANCY

    2-5 Day Bright Futures Previsit Questionnaire Bright Futures Handout
    1 Month Bright Futures Previsit Questionnaire Bright Futures Handout
    Ages & Stages Handout
    2 Month Bright Futures Previsit Questionnaire Bright Futures Handout
    Ages & Stages Handout
    4 Month Bright Futures Previsit Questionnaire Bright Futures Handout
    Ages & Stages Handout
    6 Month Bright Futures Previsit Questionnaire Bright Futures Handout
    Ages & Stages Handout
    9 Month Ages & Stages Questionnaire (8 month)
    Ages & Stages Questionnaire (9 month)
    Bright Futures Handout
    Ages & Stages Handout

    EARLY CHILDHOOD

    12 Month Ages & Stages Questionnaire Bright Futures Handout
    Ages & Stages Handout
    15 Month Bright Futures Previsit Questionnaire Bright Futures Handout
    Ages & Stages Handout
    18 Month Ages & Stages Questionnaire
    M-CHAT
    Bright Futures Handout
    Ages & Stages Handout
    2 Year Bright Futures Previsit Questionnaire
    M-CHAT
    Bright Futures Handout
    Ages & Stages Handout
    2.5 Year Ages & Stages Questionnaire Bright Futures Handout
    Ages & Stages Handout
    3 Year Bright Futures Previsit Questionnaire Bright Futures Handout
    Ages & Stages Handout
    4 Year Bright Futures Previsit Questionnaire Bright Futures Handout
    Ages & Stages Handout

    MIDDLE CHILDHOOD

    5 Year Bright Futures Previsit Questionnaire Bright Futures Handout
    Ages & Stages Handout
    6 Year Bright Futures Previsit Questionnaire Bright Futures Handout
    7 Year Bright Futures Previsit Questionnaire Bright Futures Handout
    8 Year Bright Futures Previsit Questionnaire Bright Futures Handout
    9 Year Bright Futures Previsit Questionnaire Bright Futures Handout
    10 Year Bright Futures Previsit Questionnaire Bright Futures Handout

    ADOLESCENCE

    11-12 Year Bright Futures Previsit Questionnaire Bright Futures Handout
    13-14 Year Bright Futures Previsit Questionnaire Bright Futures Handout
    15-17 Year Bright Futures Previsit Questionnaire Bright Futures Handout

    Our Docs

    Want to know more about who we are? Press here and take a look at our Doctors and a little bit about their background.

     

    Contact Us

    Press here to contact us with any questions, concerns, or comments. We are here as a resource and your neighbor.

     

    Richmond Family Medicine
    30 West Main Street | Richmond, VT 05477
    TEL: 802-434-4123 | FAX: 802-434-3130

    Physicians: Dr. Daniel Goodyear, Dr. Hannah Rabin, Dr. Robert Areson

    Facebook Map

    Home | Urgent Care | Physicals | Womens Health & GYN Care | Pediatric | Counseling | Diabetes Care | Nutrition | Contact Us | Forms | Insurance We Accept

    Copyright © 2023 · All Rights Reserved