Board Certified Internal Medicine
Board CertifiedInternal Medicine

Forms / Links

Assorted Forms:

Medical Records Transfer Form
Medical Records Transfer Form. Use this form to request records be transferred from Bluewater Medicine to another provider.
Transfer records from Ponder 3.pdf
Adobe Acrobat document [75.4 KB]
New Patient Forms
NEW PATIENT STATUS 03SEP2020: currently NOT accepting new patients
We see patients in our Bluewater Bay office, and for house calls at the following assisted care living facilities:
Beehive Niceville, Brookdale Niceville, Superior Niceville, and Hawthorn House Shalimar.
new patient pack ccm.pdf
Adobe Acrobat document [936.9 KB]
Medicare Chronic Care Management Introduction Letter
All Medicare patient encouraged to enroll in this important benefit.
Adobe Acrobat document [87.1 KB]
Medicare Chronic Care Management Consent form
Dr. Kenneth W. Ponder consent form.pdf
Adobe Acrobat document [234.1 KB]
Medicare Chronic Care Management Tricare for Life / Federal BCBS additional info
Adobe Acrobat document [62.2 KB]
Disabled Person Parking Form
Adobe Acrobat document [192.7 KB]
Controlled Medication Management Agreement
Adobe Acrobat document [62.3 KB]
Assisted Care Living Facility Form 1823
Adobe Acrobat document [231.6 KB]
Privacy Policy
Adobe Acrobat document [91.8 KB]
Living Will / Health Care Surrogate Forms - FLORIDA
To download living will and health care surrogate forms for other states, visit
Adobe Acrobat document [106.9 KB]
Do Not Resuscitate Order
A Do Not Resuscitate Order (DNRO) is a form or patient identification device developed by the Department of Health to identify people who do not wish to be resuscitated in the event of respiratory or cardiac arrest.

Important! In order to be legally valid this form MUST be printed on yellow paper prior to being completed. EMS and medical personnel are only required to honor the form if it is printed on yellow paper.
Adobe Acrobat document [133.6 KB]

Contact Us:

Bluewater Medicine
4566 E Hwy 20 Ste 103
Niceville, FL 32578



+1 850 897-1223+1 850 897-1223

Fax:     +1 888 423-5018

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