New Patient Intake Form

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Step 1 of 9

Taral Sharma, M.D., P.C.
(Carolina Psychiatry)
Phone: (864) 844-9432
Fax: (864) 844-9430

Demographics

Legal name as it appears on your driver's license/ state ID
Best call back number (preferably cell phone number)
If you don't have an email address, please write N/A
Physical Address (i.e., 10 Financial Blvd., Anderson SC 29621)
Sex
Marital Status
Please provider Name, Your relationship & Phone Number (i.e., John doe, Spouse, 864-844-9432)
Do you have health insurance?
You may be required to bring your insurance card at the time of your appointment