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Patient Information Form for Dr. G. Scott Sparrow
City, State, Zip
Father's name is patient is a minor
Father's DOB if patient is a minor
Mother's name if patient is a minor
Mother's DOB if patient is a minor
Has the patient been in counseling/psychotherapy, or under psychiatric care?
If so, please provide the therapist/counselor and/psychiatrist name(s).
Has the patient been involved in a lawsuit, or other legal action?
If so, please provide the attorney's name(s)
Is the patient covered by insurance?
If so, please provide the name of the insurance company.
Blue Cross of Texas
United Behavioral Health
Subscriber Date of Birth
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