Forms

MEDICAL RECORDS RELEASE (TO EFH)

Allows Evergreen Family Health to obtain medical Information from another medical office or other source.

MEDICAL RECORDS RELEASE (FROM EFH)

Allows Evergreen Family Health to send medical information from your record to a third party such as an employer, insurance company, or other health care provider.

RECORDS RELEASE (MV ACCIDENT)

Authorization for medical record release in the event of a motor vehicle accident.

RECORDS RELEASE (WORKERS COMP)

Allows EFH to obtain medical Information in the event of Workers Compensation filing.

PERMISSION TO DISCUSS MEDICAL CARE

Allows EFH to share your medical care with family members and others of your choosing.

VERMONT ADVANCED DIRECTIVE

Living Wills and advanced directives describe your end-of-life care. EFH advises that all adults have an advanced directive on file.

ADULT HEALTH DATABASE

Form for initial health exam – “Complete Physical”

ADULT HEALTH DATABASE UPDATE

For follow-up or annual “PHYSICAL”

Request An Appointment

Visit the patient portal to request a date for your next appointment

VISIT PATIENT PORTAL