New Patient Onboarding — Cognitive Works PLLC

1 Review

2 Info & Card

3 Agreement

In order to finalize your appointment, all of the steps below must be completed.

A valid credit or debit card is required to complete onboarding. A temporary $100 hold (not a charge) will verify your card and is released immediately.

Have your insurance card images ready (front & back) — you will upload them as part of the patient agreement. If you are paying out of pocket, insurance cards are not required.

After card verification, you will complete a patient agreement through BoldSign, a secure electronic signature platform, to finalize your onboarding.

I have read and understand the above requirements

Patient Information & Card Verification

Complete each section below to proceed.

Patient Information

Enter the patient's details

Confirmed A

Patient First Name * Required

Patient Last Name * Required

Phone Number * Required

Email Address * Valid email required

Edit

Credit Card Verification

Cardholder may differ from patient

VISA MC AMEX DISC

Name on Card *

Card Number *

Month *

Year *

CVV *

Please wait... verifying your card. Do not close or refresh this page.

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