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Back to Health offers our patient form(s) online so they can be completed it in the convenience of your own home or office.

  • If you do not already have AdobeReader�® installed on your computer, Click Here to download.
  • Download the necessary form(s), print it out and fill in the required information.
  • Fax us your printed and completed form(s) or bring it with you to your appointment.

This lets us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!

New Adult Patient Health History Forms- Required

Download & Print Form

New Adult Medicare Patient Health History Forms - Required

Download & Print Form

New Child Patient Health History Forms - Required

Download & Print Form

New Adult Auto Health History Forms - Required

Download & Print Form

New Child Auto Health History Forms - Required

Download & Print Form

New Worker's Comp Health History Forms- Required

Download & Print Form


Member Wellness Registration Form - Optional

This form can be filled out to register for access to the member wellness section of our website. You can also sign up for our monthly newsletter to keep up on current health issues and news and events in our office. You can print it out and bring it in to our office or Click Here to register online! The online newsletter sign-up is also on the right. We look forward to making your experience with our office and website more interactive and rewarding!

Download & Print Form



Download the Free AdobeReader�®

New patients receive a Free Consultation.

 

Sign-up using the form or call us at 802-527-2225 to take advantage of this exclusive offer.

THIS ---->https://drmolly.com/new-patient-center/new-patient-forms.html

Office Hours

Day
Monday8am - 12pm1:30pm - 5pm
Tuesday8am - 12pm1:30pm - 6pm
Wednesday8am - 12pm1:30pm - 6pm
Thursday8am - 12pm2pm - 5pm
Friday8am - 12pm1:30pm - 3pm
SaturdayClosed *Emergencies seen.
SundayClosed *Emergencies seen.
Day
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
8am - 12pm 8am - 12pm 8am - 12pm 8am - 12pm 8am - 12pm Closed *Emergencies seen. Closed *Emergencies seen.
1:30pm - 5pm 1:30pm - 6pm 1:30pm - 6pm 2pm - 5pm 1:30pm - 3pm

Testimonial

The staff was very nice and caring. I recommend you to go if needed. from Dr. Keefe.

Cindy M.
St. Albans, VT

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