New Patient Info Name First Middle Last Home PhoneCell/Alternate PhoneEmail Home Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code SexMaleFemaleBirth Date Date Format: MM slash DD slash YYYY AgeLast 4 digits of SS#Marital StatusMarriedSingleDivorcedReason For VisitReferring PhysicianPhonePrimary Care PhysicianPhoneEMPLOYEREMPLOYER'S ADDRESSCITYSTATEEMPLOYER'S PHONEOCCUPATIONIN CASE OF AN EMERGENCYRelationPhoneDO YOU HAVE A DRUG CARD?YesNo 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.*CAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.