New Patient Appointment Request
Telehealth Psychiatry · Dr. Matthew Sachs, MD, MPH, MBA · Virginia & North Carolina Please complete this form in its entirety. Red asterisk fields are required. Submissions go directly and discreetly to our office. We'll respond 24-48 business hours.
Patient's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Gender
*
Male
Female
Prefer Not to Answer
Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Information
Phone # where you can be texted. This is our primary mode of communication.
*
Format: (000) 000-0000.
Email Address
*
example@example.com
Parent / Guardian Name
First Name
Last Name
Relationship to Patient (if completing on behalf of a minor)
Please Select
Mother
Father
Sister
Brother
Guardian
Grandparent
Other
Child
Other
Insurance Information
Health Insurance Name
*
Insurance ID Number
*
Clinical Information
Main Reason for Appointment
*
How did you find our practice? If transferring from another provider, please explain why.
*
Current Diagnosis or Diagnoses
*
Current Medications and Doses
*
Current or Previous Mental Health Providers
*
Have you been hospitalized previously for mental health?
*
Yes
No
If yes, please describe: where, when, and reason(s)
We communicate primarily by text message using the mobile number provided above. You may also text us directly at 757-219-2753. After submitting this form, we make every effort to respond to appointment requests promptly, typically within 48 business hours. We pride ourselves on being highly responsive during regular office hours: Monday–Thursday, 9:00 AM–4:00 PM. The office is closed otherwise, though we still try to respond to messages daily. For psychiatric emergencies or urgent safety concerns after hours, please call 911 or go to the nearest emergency room.
*
Yes, agreed.
I understand that Dr. Sachs conducts independent psychiatric evaluations and that his diagnostic impressions and treatment recommendations may differ from those of other providers, including with respect to ADHD. Prior records, psychological testing, and reports from other providers are helpful and may be emailed to matthewsachsmd@gmail.com or faxed to 804-207-8706; however, they do not replace Dr. Sachs’s independent clinical assessment and judgment.
*
Yes, agreed.
I understand that responses to text messages and medication requests require up to 48 business hours to fill. The office is closed Friday–Sunday. For psychiatric emergencies after hours, I will call 911. I understand that I am responsible for joining telehealth appointments on time. I can change appt's on the patient portal. A late arrival on Zoom may result in a shortened session, and a no-show charge may result if you are not online after 10 minutes. My after-visit summary contains my next appointment info, and text confirmations are also sent to my phone prior to my appt.
*
Yes, agreed.
Our office uses a HIPAA-compliant messaging platform designed to help protect your privacy and personal health information. HIPAA-compliant AI may be used to support note generation, so more time can be spent talking directly with you during appointments. Audio is never preserved.
*
Yes, agreed.
I have read and agree to the office information, financial terms, and expectations outlined on this form, and on www.matthewsachsmd.com, including the Payment page. I understand that updates may be made periodically and posted on the website. By clicking SUBMIT below, I agree to these terms and the accuracy of the information I have provided on this form.
*
Yes, agreed.
Signature
Patient or Parent/Guardian Signature
*
Today's Date:
*
-
Month
-
Day
Year
Date
Submit Appointment Request
Should be Empty: