Forms & Policies

New patients:
Records Transfer Form (Complete and give to us or your former provider’s office)
General Consent Form  (Sign and give to us)
Initial History Questionnaire  (Complete and give to us)
Immunization and Physical Exam Schedule

Sports Physical Forms

History Form for ALL schoolss
Vermont Sport Form

New York Sport Form

What to Expect at Visits

Save time in appointments by printing and completing the highlighted forms associated with each visit before you arrive!

MMR policy
Measles can be a severe, debilitating, and even deadly illness for children.  It is also highly contagious.  At Middlebury Pediatric and Adolescent Medicine, we care for many patients, who, because of prematurity, immune system problems, or the inability to be vaccinated due to young age, are at high risk for severe consequences of measles infection.  These patients often have frequent visits at MPAM, potentially increasing their risk of exposure.

In order to protect all of our patients, including the most vulnerable, the physicians at Middlebury Pediatric and Adolescent Medicine have determined that we must require vaccination against the measles virus.  To remain in this practice, children must receive the MMR vaccine unless it is medically contraindicated.  We are unable to make any exceptions for religious or philosophical exemptions.

The MMR vaccine is extremely effective and well-tolerated, and we are confident in the safety of this vaccine for your child.   However, we understand if you have concerns or questions regarding this new requirement, and we welcome you to call or schedule an appointment if you would like to discuss it further.
We thank you for your understanding and willingness to help protect both your child, and the most vulnerable members of our practice from this dangerous illness.

Late policy
If you arrive more than 15 minutes past your scheduled appointment time we may need to reschedule your appointment.

No show policy
We understand that life happens and you may not always be able to make it to your appointment. Please let us know as soon as possible if you cannot make it. If we do not hear from you, we will consider it a no show appointment. After the second no show, we will send you a letter. After the third no show, our care coordinator will contact you to see if she can help you make future appointments. If there is a fourth no show, we will be forced to dismiss you from the practice.

Please contact your pharmacy to request medication refills, including any controlled substances. This also applies if you have no refills left on your bottle(s). Your pharmacy will  contact us with your medication needs. Refill requests take 48 to 72 hours (or 3 business days) to process. Requests made on a Friday will be processed the next business day.

Unfortunately, we cannot process refill requests over the weekend.