Pondworks Psychiatry & Psychotherapy

Available Forms

Compliment A Pondworks Employee New Patient Form 1 of 7: Patient Contact Information New Patient Form 2 of 7: Practice Policies New Patient Form 3 of 7: Privacy Practices New Patient Form 4 of 7: Patient Portal Agreement New Patient Form 5 of 7: Review of Systems New Patient Form 6 of 7: Medications List New Patient Form 7 of 7: Consultation Informed Consent Questionnaire # 1 of 3: PHQ-9 Questionnaire # 2 of 3: GAD-7 Questionnaire # 3 of 3: Q-LES-Q-SF Telemedicine Consent Telemedicine Practice Policies

New Patient Form 4 of 7: Patient Portal Agreement

Pondworks Patient Portal Agreement

Patient Legal Name *

Patient Date of Birth *

Email Address *

Authorization for Use of Patient Portal and Electronic Communication

The Pondworks Patient Portal provides a secure, HIPAA-compliant way for our patients to communicate electronically with our front office regarding non-urgent administrative issues, such as scheduling and billing. By signing this form, I understand that the response time for the Pondworks Patient Portal is 1-3 business days and that it is not intended for clinical questions or emergencies. I agree that, if I have a clinical question?a question about my treatment, medications, or any changes in my mental health?I will call my provider and leave a confidential voice mail. If I am having an emergency, I will call 911. If I need a refill on my prescription, I will first call my pharmacy. I understand that anyone who knows my email address and password may be able to access the information in the patient portal, and I will take appropriate steps to protect my own privacy.

I have read the above authorization and agree to all aspects so specified. *

Agree

Do Not Agree

Electronic Signature: Name *

Date *

* Required field