Shannon Wells DDS

  
 21/15/01
 02:58 PM 
 TO: 16103548946 FROM: 8333674968 
 Page 48 
 SIMONS, CHARLES 
 C11920 DOB:08/18/1961 
 PRADA, S. MD 
 PATIENT REGISTRATION FORM 
 Date 
 Patient Name 
 Social Security Number 
 21/15/01
 Charles SIMONS 
 26359xxxx 
 Date of Birth 
 Home Phone 
 Cell Phone 
 Address including City, State and Zip Code: 
 16/86/06
 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. 

 08/21/10
 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
