Piedmont Psychiatric Services Contact Form
CONTACT NAME
*
CONTACT NUMBER
*
CONTACT EMAIL
*
PATIENT NAME
*
PATIENT DATE OF BIRTH
*
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Month
-
Day
Year
REASON FOR CONTACT:
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Appointments - EXISTING PATIENT
Appointment Questions - NEW PATIENT
Medication Questions/Refills
Billing and Insurance Questions
Medical Records/Correspondence/Form Needs
For Medical Providers
WHAT TYPE OF APPOINTMENT WOULD YOU LIKE?
*
In-Office
Virtual
INSURANCE NAME
POLICY NUMBER
INSURANCE CARD (FRONT): PLEASE UPLOAD A PICTURE
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INSURANCE CARD (BACK): PLEASE UPLOAD A PICTURE
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Choose a file
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CURRENT MAILING ADDRESS
IF YOU ARE A MEDICAL PROVIDER, PLEASE SELECT YOUR QUESTION TYPE:
Referral Questions
Mutual Patient Questions
PLEASE SELECT YOUR PROVIDER OR THERAPIST:
*
Tony Goodbar, MD
Jeffrey Smith, MD
Joseph Friddle, PA-C
Sydney Broxton, PMHNP
Carrie Ballenger, PMHNP
Ingrid Miller, MSW, LISW-CP
Michael Smith, LPC
Zachary Adams, LISW-CP
Jacklyn Murphy, LMFT
Zoe R. Daab, LMFT, VSP
Tina M. Robertson, LMFT
PREFERRED DATE #1
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Month
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Day
Year
Date
TIME RANGE FOR DATE #1
ex: 8:00 AM to 12 PM
PREFERRED DATE #2
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Month
-
Day
Year
Date
TIME RANGE FOR DATE #2
ex: 8 AM - 12 PM
PREFERRED DATE #3
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Month
-
Day
Year
Date
TIME RANGE FOR DATE #3
ex: 8 AM - 12 PM
IS THIS A REQUEST FOR A MEDICATION REFILL?
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YES
NO
MEDICATION NAME & DOSAGE (Note: If requesting a medication refill, you MUST provide the Pharmacy Name and Phone Number)
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PHARMACY NAME
PHARMACY PHONE NO
MESSAGE
NOTE:
If this is regarding scheduling an appointment for an existing patient in this practice, we will try our best to accomodate this request.
If this is regarding a medication refill, please allow 24 hours for the refill to be sent to your pharmacy.
Please allow 24 hours for a response to your request. If you need a response quicker, then call our office at 864-676-9211 during normal business hours of Monday - Thursday 8am - 4pm.
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