Patient Registration Information

Your Email     Auto accident? Please enter date of injury

PATIENT INFORMATION   Marital Status   Single   Married   Divorced   Widowed Sex   Male   Female

Last Name   First name initial Street address (Apt# ) City State Zip Home phone Work Phone Social Security# Date of Birth Driver's License: (State & Number) Employer/Name of School Full Time Part Time Address (Apt# ) City State Zip Your occupation Spouse's Name Spouse's Home Phone Spouse's Employer's name Spouse's Work Address (Apt# ) City State Zip How do you wish to be addressed? Social Security#

PATIENT'S / RESPONSIBLE PARTY INFORMATION

Responsible party Home phone Date of Birth Relationship to Patient:     Self     Spouse     Other   Social Security# Address City State Zip

PATIENT'S REFERRAL INFORMATION

Referred by If referred by a friend, may we thank her or him? YES NO Referred: TV Website N.J. Naturally Name(s) of other physicians(s) who care for you

EMERGENCY CONTACT

Name of person not living with you Relationship Address (Apt# ) City State Zip Home phone Work phone

I understand that Sharda Sharma, M.D. provides holistic consultation services only, and that she is not a primary care physician. Any consultations I have with her are not substitutes for visits with my regular physician. For routine care, urgent care or emergency services, I will contact my primary care physician.
My primary care physician is Dr. , whose office is located at , and whose office telephone number is .
WE DO NOT PARTICIPATE WITH ANY INSURANCE