Pondworks Psychiatry & Psychotherapy

Pondworks Psychiatry & Psychotherapy

Patient Contact Information

Legal Name * Preferred Name (if different) Date of Birth * Social Security Number Street Address * Apartment # City * State * ZIP Code * Primary Phone Number * Phone Type * Email * Sex * Gender * Preferred Pronouns * Emergency Contact Name * Emergency Contact Phone Number * Preferred Pharmacy * Pharmacy Address * Type of Account * Insurance Company Name Insurance Policy ID # Insurance Policy Group # Insurance Company Mailing Address Insurance Subscriber Mailing Address (if different from patient address) Subscriber City, State, ZIP Code Subscriber Date of Birth

We require a credit card number on file for all telemedicine visits. We will charge your credit card for deductibles, co-payments and other balances due. Payment plans are available upon request!

Credit Card Number * Credit Card Expiration Date (MM/YY) * Credit Cardholder's Billing ZIP Code Credit Card Security Code * I give permission for Pondworks to communicate with me through the following means. Reasonable steps will be taken to ensure the confidentiality of the above means of communication, which are not secure and could be inadvertently received or overheard by an unintended third party * Electronic Agreement: I have read the above authorization and agree to all aspects so specified. * Date *