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.

  • Release information to/from Richmond Family Medicine
  • Patient Consent Form - Family & Friends
  • Telemedicine Consent Form
  • Flu Vaccine Questionnaire and Consent Form
  • New Patient Registration Packet
  • Annual Health History Update
  • Medicare Annual Wellness Visit Questionnaire
  • Medicare Information Packet
  • Advance Directive Short Form
  • Advance Directive Long Form
  • Worker’s Compensation Form
  • Psychiatric Intake Packet
    • 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
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