Rockingham Natural Health Clinic

Wholistic Pediatric and Family Medicine

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Forms and privacy policy (Word documents)

Adult Intake Form
Child Intake Form
Treatment Consent Form
Insurance Information
Medical Records Release
HIPAA Privacy Policy
HIPAA Notice of Privacy Practices
Acknowledgement of Receipt of Notice of Privacy Practices

©2011 Rockingham Natural Health Clinic | 802.869.1222

10 Main Street, PO Box 249, Saxtons River, Vermont 05154

Serving: Saxtons River, Rockingham, Bellows Falls, Westminister, Putney, Brattleboro, Springfield, Chester, Grafton, Norwich and White River Junction, Vermont.