New Patient Appointment Request

All visits are by appointment only. This is Not a walk-in or urgent care clinic. You must have an appointment to be seen by one of our providers. NO WALK-INS WILL BE ACCOMMODATED.

Clinic Hours: Saturday Only, 8:30 am – 12:30 pm
Who Can Be Seen? Adult Patients 18+ years old

Step 1: Please fill out the information below and submit it when completed.
Step 2: Our scheduler will contact you within 48 – 72 hours.

If this is an emergency, please call 911 or visit the nearest emergency room

Date
Date of Birth
First Name
Last Name
Sex



Email
Phone (Cell)
Phone (Home)
When is the most convenient time for us to contact you? Please provide a range of time that suits you best (e.g., between 10 am – 2 pm, 4 pm – 5:30 pm, etc.).
Do you use Assistive Device(s)?















Reason for your visit:
Have you been vaccinated against Covid-19?


If Yes, please indicate how many vaccine doses:




Do you have insurance coverage?


If No and need financial assistance for medications and/or labs and X-rays, please provide the following information:

1) Number of people in your household:
2) Total family income:

*Family income includes Salary, social security, disability, Veteran’s benefits, pensions, SNAP benefits, unemployment compensation, child support, etc.
Please provide a list of all the hospitals and clinics where you have received medical care (University of Vermont Medical Center, Community Health Center, etc.):
Do you require an interpreter or translator?


If Yes, please indicate your language of preference:
Do you have any other concerns or comments you would care to share?
This form was completed by:


Authorized Patient Representative Name:
The form has been submitted successfully!
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