Play OnWords Initial Contact Form
Thank you for reaching out to POW! Shortly after completing this form, you will receive a "Welcome" email from our patient portal software: Please follow the directions to create a password, log in, and complete our intake form.  Once the intake forms are completed, we schedule the initial appointment with the appropriate specialist. Should you have any questions, please do not hesitate to contact us: or 340-727-7529 (text,  WhatsApp, voice).
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Email *
Patient's Name (First, Last) *
Patient's Birthdate *
Legal Guardian's Name and Relationship to Child: *
Guardian Phone Number:
Guardian Email: *
General Concerns:
Health Insurance
We accept almost all health insurance plans offered in the USVI: Cigna, MAP, MAPFRE, UHC, Aetna International, ELAN, Triple S, UBS. If your company is not listed, please still provide your insurance information. 
Do you have active health insurance? *
If you have health insurance, list the name of the company and membership number:
How did you hear about us? *
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