TARAL SHARMA, MD, PC

120 PELHAM LN

Phone: (864) 844 – 9432

Fax: (864) 844-9430

New Patient Information

Full Name:
Preferred Name:
Street Address:
City
State:
Zip Code:
Main Phone:
Date of Birth:
Social Security Number:
Driver’s License or Government Issued ID:
Marital Status
Sex:

INFORMATION:

PLEASE BRING YOUR INSURANCE CARD WITH YOU TO YOUR APPOINTMENT.

Insurance Company:
Type:
ID Number:
Group Number:
Subscriber Name:
Birthdate:
Relationship to Subscriber:

ADDITIONAL CONTACT INFORMATION

Secondary Phone:
Home E-mail:
Work E-mail:
Emergency Contact Name:
Emergency Contact Phone:
Relationship to you:
Your Primary Care Provider:
Primary Care Provider Phone:
Other Provider:
Other Provider Phone:
Pharmacy Name:
Pharmacy Phone:
Pharmacy Location:

Adult Patient Intake Form

Dear Patients: Please carefully fill in this form prior to your first appointment in order to help us reduce the time and cost of gathering this information at our office. We appreciate your cooperation and patience.

Patient’s Name:
Who referred you to our practice?
Please briefly describe the problems for which you are seeking help at this time.
Approximately when did the problem(s) begin?
Any known stress cause or contribute to the problem(s)?
Have you ever received outpatient mental health treatment?

Medical History:

Who is your Internist or Family Doctor?
Do you have any drug allergies?
Do you have any current medical problems?

I agree that the above information is correct to the best of my knowledge.

Signature:
Date