PATIENT INFORMATION
The Shell Center
Acct No. (office use only):
( ) Adult ( ) Child
Today’s Date:
Name:
( ) Male ( ) Female
Date of Birth:
Address:
SSN:
City:
State/Zip:
Marital Status:
Home Phone:
Cell Phone:
Work Phone:
Emergency Contact:
Pharmacy:
Emergency Contact Phone:
Pharmacy Location:
Referring Physician:
Primary Care Physician:
PERSON RESPONSIBLE FOR BILL IF NOT SELF:
( ) Spouse ( ) Parent ( ) Guardian ( ) Other
Complete this Section if PERSON RESPONSIBLE FOR BILL is NOT you
Name:
Employer:
Date of Birth:
Address:
SSN:
City:
State/Zip:
Home Phone:
Work Phone:
INSURANCE INFORMATION or provide a copy of your insurance card. Do NOT complete if you provide a copy
of your insurance card
Company:
Group #:
Address:
ID #:
Phone Number:
Please READ and SIGN the following:
I hereby authorize payment of BENEFITS due me to the physician’s office for all services rendered. I hereby authorize
the physician/provider to RELEASE any information required to process my insurance claim form. I certify to the
ACCURACY of the above information. I understand that I am FINANCIALLY RESPONSIBLE for all charges,
regardless of any insurance coverage. A copy of this signature is as valid as the original.
_________________________________________________________
Signature
The Shell Center
630 15th Avenue, Suite 104
Longmont, CO 80501
________________________________
Date
Phone 303.772.3698
Fax 303.772.3707
Revised December 2012