Initial Patient Forms
The links below will open up as PDF documents that you can fill out once you download them to your computer. Please print them out and bring them with you to your appointment, along with your insurance card.
- Pondworks Patient Contact Information Form (signature required)
- Pondworks Practice Policies (signature required)
- Pondworks Acknowledgement of Privacy Practices (signature required)
- Pondworks Consultation Informed Consent (signature required)
- My Medicine Record (required)
- Medical Review of Systems (required)
- Pondworks Privacy Practices (for your information only; no signature required)
- Pondworks Patient Portal Agreement (signature required)
- Directions to Pondworks (print out)
Other Patient Forms
If you will be requesting medical records from another provider, OR giving permission for Pondworks to share confidential information (medical and/or billing) with someone, please complete the form below. PLEASE ASK US if you are confused!!
- Pondworks Request Records BK (Bernard Kim, MD)
- Pondworks Request Records TF (Tracy Figlan, PMHNP-BC)
- Pondworks Request Records JC (Justin Cullers, PMHNP-BC)
- Pondworks Request Records LC (Lauren Cone, PMHNP-BC)
- Pondworks Request Records ABC (Amanda Corley, PMHNP-BC)
- Pondworks Request Records HyH (Hyojin Han, PMHNP-BC)
- Pondworks Request Records KDG (Kelly Gadbury, LPC)
- Pondworks Request Records CW (Candyce Willis, PMHNP-BC)
- Pondworks Request Records IS (Ivan Srdanovic, PMHNP-BC)
The following forms are for you, to help with understanding your behavioral health insurance coverage:
Pondworks – Insurance Terminology