Craig Avila

  
 2015 June 27
 02:58 PM 
 TO: 16103548946 FROM: 8333674968 
 Page 79 
 SIMONS, CHARLES 
 C11920 DOB:08/18/1961 
 PRADA, S. MD 
 PATIENT REGISTRATION FORM 
 Date 
 Patient Name 
 Social Security Number 
 2015 June 27
 Charles SIMONS 
 26359xxxx 
 Date of Birth 
 Home Phone 
 Cell Phone 
 Address including City, State and Zip Code: 
 1986 March 20
 877833xxxx 
 Marital Status: 
 Hispanic or Latino 
 American Indian or Alaska Native 
 White 
 Single 
 Divorced 
 Non-Hispanic or Latino 
 Asian 
 Other 
 Black of African American 
 Unknown 
 May the Surgery Center leave a detailed voice message on your phone
 Yes 
 No 
 May the Surgery Center email you detailed information via the email you provided 
 Yes 
 No 
 Email Address 
 Patient Employer/Phone 
 
 Insured Subscriber Name, Date of Birth and Social Security Number 
 If under LOP Attorney Name and Phone Number 
 Emergency Contact Info: 
 Sherry Name: 
 wits 
 Relationship: 
 Phone: 
 Commercial/Medicare/Auto/Workman's Compensation Lifetime Assignment 
 OWNERSHIP ACKNOWLEGEMENT/ANTI-DISCRIMINATION POLICY 
 
 have received a written copy of my patient rights and responsibilities. 
 I have received a copy of the center's Anti-Discrimination Policy. 

 2017 September 17
 Signature of Patient or Patient's legal representative if Patient is unable to sign 
 Date 
 Relationship to Patient if Patient is unable to sign 
 M a 
 4/4/85 
 Signature of Witness 
 Date
