We encourage our patients to print and fill out paperwork in advance. You may mail your completed forms (1775 Williston Rd., Ste. 110, So. Burlington, VT 05403); fax them (fax: 802-862-9637); or bring them with you to your appointment.
Some forms may be submitted electronically, all other forms below are Acrobat PDF files that you can download and print.
New Patients
Due to limited availability, we are currently only accepting new self-referred patients for urgent appointments. We appreciate your understanding and encourage you to complete our pre-registration form to get added to our waitlist and check back in three months for appointments availability.
If you are a new patient and already have an appointment scheduled, please fill out these forms…
For Electronic Submission:
Initial Intake Form (only complete if you already have an appointment scheduled)
Patient Information Form and Request For Medical Services (HIPAA) – sign after
reading Notice of Health Information Privacy Practices
Notice of Health Information Exchange (HIE)
For Printable Versions:
Patient Information Form and Request For Medical Services (HIPAA) – sign after reading Notice of Health Information Privacy Practices
Notice of Health Information Exchange (HIE)
Returning Patients
If you are a returning patient, please fill out these forms:
Notice of Health Information Exchange (HIE) (if you have not already signed)
Release of Records To or From Vermont Gynecology
If you are transferring your care to Vermont Gynecology from another practice or seeking a consultation/second opinion, please complete our Record Release Form and send it to your current provider.
If you are requesting that your records be sent from Vermont Gynecology to another provider, please complete our online Record Release Form. Once submitted we will process your request. Alternatively, if you prefer you may download and return our printable version instead.
- Record Release Form (online version)
- Record Release Form (printable version)
Information Forms and Procedure Consents
If you are having a procedure at Vermont Gynecology, we encourage you to read the appropriate Fact Sheet, sign the Consent, and bring the form with you to your appointment.
Functional Medicine Intake Form
IUD Insertion Pre- and Post-procedure Instructions
Nexplanon Insertion Information Sheet
Colposcopy Fact Sheet & Consent
Endometrial Biopsy (EMB) Pre- & Post-procedure Instructions
Endometrial Biopsy (EMB) Fact Sheet & Consent
Vulvar Biopsy Fact Sheet & Consent
Guidelines for Vulvar Skin Care
Sonohysterogram Fact Sheet & Request for Surgery Form
If you are having another procedure at Vermont Gynecology, please read, sign, and return:
Procedure / Surgery Consent Form
Surgery Information
When you come in for a surgical consultation, your doctor will give you a very detailed handout about preparing for surgery. It covers everything you will want and need to know about how to get ready for surgery; what it will be like at the hospital or surgery center; activity and diet instructions for your optimal recovery; shopping lists; nutritional tips, etc. Our patients say this is an invaluable tool for them and continue to refer to it every step along the way. While this process is very familiar to us, we know that it is new to you. We want you to be as prepared as possible, and we do not want you to have surprises. We are committed to preparing you as well as possible for this significant step in your life.
In addition to this handout provided by your doctor, you may also refer to the following helpful information from the hospital and surgery center where your surgery will take place: