New Patient Info

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Name:
Email:
Home Phone:
Cell/Alternate Phone:
Sex:
Birth Date:
SS#
Home Address:
Martial Status:  Married Single Divorced
Reason For Visit:
Primary Care Physician:
Phone:
Referring Physician:
Phone:

Insurance Provider:
Insurance ID#
Insurance Group #
Insurance Provider Phone #

Employer:
Employer Address:
Work Phone:
 Full-Time Part-Time Retired

Person to be reached in case of emergency:
Relation:
Phone:

I hereby authorize Dr. Shashi Dharma’s office to release written or verbal information to my doctor or insurance carrier (if the information is requested). In consideration of services rendered, I hereby assign to Dr. Dharma benefit payments due from my insurance company for medical expenses incurred which are payable to me.

I have been informed of or received a copy of the “Notice of Privacy Practices.”

Payment is due at time of service! This includes all copays, deductibles, and any other non-covered items.

A $25 fee will be charged for all “NO SHOW” appointments
not canceled at least 24 hours in advance.

 I accept the above terms and are responsible of any incurring charges.