Dr. Sachs - Appointment Request Form

HIPAA-Compliant Appt Request Form

Dr. Matthew Sachs, MD, MPH, MBA
Please complete this form to the best of your ability. Anything with a red star is required. Submissions go directly to our office, and my staff will do their best to respond within 24-48 weekday hours unless on vacation or holiday. If we can take you on as a patient, we will be sending you additional information ASAP. Thank you for submitting your request.
Patient's Name*

First NameLast Name
Patient's Age*
Patient's DOB:*

MonthDayYear
Date
Today's Date:*

MonthDayYear
Date
How did you choose our practice? If you have been seeing someone else, why the change?*
Patient's Gender*

MaleFemalePrefer Not to Answer
If filling this out for a patient < 18, please state relationship
Please give the main parent/guardian name.

First NameLast Name
Email of Patient (18+), Parent*
example@example.com
Phone # where you can be texted. This is our primary mode of communication.*
We communicate by texting your mobile phone # above. You can text us at 757-219-2753. Are you OK with this?*

Yes
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Main Reason for Appt*
Current Medications and Doses*
Current or Previous Psychiatrist(s), Psychologist(s), or Therapist(s)*
Diagnosis or Diagnoses*
Hospitalized Previously for Mental Health*

YesNo
If hospitalized, where, when, reason(s)?
Patient's Health Ins. Name *
Patient's Insurance ID #*
I have read and agree with the financial policies and prices as outlined on www.matthewsachsmd.com under the Payment section. If anything changes, there will be advance notice posted. Please check it occasionally.*

Yes: If you agree, please continue
After submission, if we’re able to accept your case, we’ll send you a secure, encrypted link (protected by our cyberinsurance policy) to provide your credit card. A non-refundable deposit will be charged which guarantees your appointment slot with Dr. Sachs. You’ll immediately receive access to a private Patient Portal, where you can easily schedule your intake appointment on a date that works best for you.*

Yes: If you agree.
You can always contact the office by texting 757-219-2753. Responses or any refills require 24-48 working business hours. The office is closed Friday-Sunday. Any psychiatric crisis after hours should be handled by calling 911.*

Yes: If you agree.
We will always meet here for our appointments: this is an encrypted Zoom room.

https://us04web.zoom.us/j/7325240046

Please bookmark. Please test your Zoom app before the first appointment to make sure the camera and microphone work. This will help w/ time and technical issues.

Any other questions can be answered here: www.matthewsachsmd.com or simply by texting us at 757-219-2753. We pride ourselves in our response time to you.
Patient or Parent/Guardian Signature*

Clear
Should be Empty:

HIPAA-Compliant Appt Request Form