New Patient Info - Mahendra Mahatma, M.D., P.A.

Name
First Middle Last
Home Phone
Cell/Alternate Phone
Email
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Sex
Birth Date
Date Format: MM slash DD slash YYYY
Age
Last 4 digits of SS#
Marital Status
- Married
- Single
- Divorced
Reason For Visit
Referring Physician
Phone
Primary Care Physician
Phone
EMPLOYER
EMPLOYER'S ADDRESS
CITY
STATE
EMPLOYER'S PHONE
OCCUPATION
IN CASE OF AN EMERGENCY
Relation
Phone
DO YOU HAVE A DRUG CARD?
I hereby authorize, Dr. Mahendra Mahatma's office to release written or verbal information to my doctor or insurance carrier, should information be requested. In consideration of services rendered, I hereby assign to Dr. Mahatma, benefit payments due from my insurance company for medical expenses incurred which are payable to me.

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

I have been informed of or received a copy of the "Privacy Notice".

A $25 fee will be charged for all "NO SHOW" appointments not cancelled at least 24 hours in advance.
Consent*
I accept the above terms and are responsible of any incurring charges.*
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