Dr. Gerald B Harris, II

Last Name * First Name * Middle Name Social Security Number * How did you hear about Dr. Harris? Marital Status * Race * Language Preference * Date of Birth * Age * Sex * Street Address * Home Phone * Cell Phone Email Address Employer Work Phone # It is ok to leave messages on the following: * Pharmacy Name and Location In Case of Emergency Permission to speak with the following people regarding my care DO NOT speak to the following people regarding my care Primary Insurance * Insurance ID # * Group # Subscriber Name, DOB, and SSN Secondary Insurance Insurance ID # Group # Subscriber Name, DOB, and SSN