Mt. Ascutney Hospital and Health Center

Patient Forms

Medical Record

To request a copy of Your Medical Record, click here.
Please print the form, fill out completely and return via either
fax or mail to the number/address at the bottom of the form.
 

Clinic Registration - Adult & Pediatrics

Please print the appropriate form, fill out completely and mail to:
MAPP, 289 County Road, Windsor, VT 05089.
If your appointment is within five business days, please bring the
form with you to your appointment, rather than putting it in the mail.

Adult Form

Pediatrics Form

Consent to Treat Minor in Parent/Guardian’s Absence

MAHHC cannot provide non-emergenct care to minors without proper parental or guardian consent. Please complete this form and return by mail to the Mt. Ascutney Physicians Practice, 289 County Road, Windsor, VT 05089 or fax 802-674-7314. It is important that you complete this form in its entirety and note any contact numbers where you can be reached at the time of the visit should the providers need to speak with you.
 
Consent to Treat Minors in Parent or Guardian's Absence Form


Consent for Access to Electronic Medical Record

Mt. Ascutney Hospital works closely with the Dartmouth-Hitchcock Medical Center.
By filling out and signing this form you give us permission to share your medical
information, electronically, with providers at DHMC. Read the information on the
form for more detail. When completed, please mail to:
MAPP, 289 County Road, Windsor, VT 05089.

Electronic Medical Records Consent Form

Confidential Disclosure Statement

If you are applying for financial assistance:

Confidential Disclosure Form
 

Ethics Consult Request

Ethics Consult Form

 

Request to Designate Personal Representative

Personal Representative Form