Bruce Shapiro, M.D. - CONTACT FORM

Bruce Shapiro, M.D., D.L.F.A.P.A.

666 Glenbrook Road – River Suite

Stamford, Connecticut 06906

Tel (203) 327-4144

Fax (203) 327-4143

PATIENT REGISTRATION FORM

PATIENT LAST NAME ________________________ FIRST NAME ________________MID INITIAL ___

ADDRESS _____________________________________________________________

CITY _________________________________ STATE ______ ZIP CODE __________

TELEPHONES: Home __________________ Work ______________________ Cell: ____________________

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E-MAIL: _______________________________________________

DATE OF BIRTH ______________________ GENDER:   ☐ M   ☐  F   

MARITAL STATUS: SINGLE MARRIED ☐SEPARATED ☐ DIVORCED ☐ WIDOWED ☐OTHER

SOCIAL SECURITY NUMBER ________ - ________ - ________

EMPLOYER __________________________________________

EMPLOYER ADDRESS __________________________________________________

REFERRAL INFORMATION:

I was referred to Dr. Shapiro by: _______________________________________

RESPONSIBLE PERSON (IF PATIENT IS A MINOR): 

LAST NAME ____________________________  FIRST NAME ___________________

ADDRESS ____________________________________________________________

Medicare Program (please check one box): 

☐I am a participant in the Medicare program  

☐  I am not a participant in the Medicare program 

For Health Insurance Company Medication Pre-Authorizations:

Health Insurance Company: _________________________________

Health Insurance ID #: _____________________________________

Pre-Authorization Telephone #: ______________________________

I AUTHORIZE THAT, SHOULD MY HEALTH INSURANCE COMPANY REQUIRE THEIR PRE-AUTHORIZATION FOR COVERAGE OF PRESCRIBED MEDICATIONS DR. SHAPIRO MAY PROVIDE TO MY HEALTH INSURER MY PERSONAL HEALTH INFORMATION:

SIGNATURE _________________________________ DATE _________________

I UNDERSTAND THAT I AM RESPONSIBLE FOR PAYMENT FOR ALL SERVICES RENDERED AND I AGREE TO BE RESPONSIBLE FOR SUCH PAYMENT.

SIGNATURE _________________________________ DATE _________________