Patient Forms

We are happy to provide our office forms for convenient download on your home computer or also available to submit electronically through our patient portal. If you do not fill them via the portal, please print and complete the appropriate forms below, and bring them with you to your appointment. Questions about which forms you need or how to sign up for the portal? Please call our office and our staff will assist you in preparing for your visit.

New Patient Forms:

Please fill out prior to your first appointment.
New Patient Forms
Release Form

Well Visits Forms:

Save time at your visit! Click on the link below and fill out the developmental screener electronically, it will be sent to our office and ready for your visit!
Now online! Ages and Stages Developmental Screener (ASQ)

Mental Health Concerns:

Asthma Forms:

In order to view or print these forms, you will need Adobe Acrobat Reader installed. Click here to download it.

South Royalton Health Center

79 S Windsor St, PO Box 119 South Royalton, VT 05068

Office Hours

Mon-Fri: Phones open at 8:00 AM, visits start at 9:00AM. Closed from 12-1 for lunch, voicemail only during lunch hour. Open until 4pm due to covid/summer hours.
On-Call Clinician available afterhours and on weekends, call main number to page.

Patient Forms

Patient Forms

South Royalton Health Center

79 S Windsor St, PO Box 119 South Royalton, VT 05068

Office Hours

Mon-Fri: Phones open at 8:00 AM, visits start at 9:00AM. Closed from 12-1 for lunch, voicemail only during lunch hour. Open until 4pm due to covid/summer hours. On-Call Clinician available afterhours and on weekends, call main number to page.

Mon-Fri: Phones open at 8:00 AM, visits start at 9:00AM. Closed from 12-1 for lunch, voicemail only during lunch hour. Open until 4pm due to covid/summer hours.
On-Call Clinician available afterhours and on weekends, call main number to page.