Sunrise Senior Daycare 2500 S Sheridan Blvd, Denver COPhone: 303-358-5399; Fax: 303-284-4231 Patient Name *Birthday *Address *City *State/Province *ZIP / Postal Code *Email *Home Phone *Cell Phone *Social Security Number *OccupationEmployer NameSex *MaleFemaleOtherLanguageMarital Status *SingleMarriedDivorcedWidowedRace *American Indian/ Alaskan NativeAsianCaucasianBlack/African-AmericanPacific IslanderDecline to SpecifyEthnicity *HispanicNon-HispanicDecline to SpecifyWho can we talk to regarding your medical care?Emergency Contact Name *Phone *Relationship to patient *Primary Care ProviderPCP Address:PCP Phone NumberPharmacistPharmacist AddressPharmacists Phone NumberCase ManagerCase Manager Phone NumberAgreement and Assignment of Benefits: I understand that I am selecting Sunrise Senior Day Care to be my primary Day Care service provider. I authorize Sunrise Senior Day Care to work with my Case manager, Primary Care Physician and Pharmacist to solidify my attendance at their facility.Digital Communication Consent: I give consent to send automated emails, texts and voice messages to the email and phone number(s) listed above for appointment reminders and for Patient Portal access.I have read and received a copy of the office HIPPA policy and consent to the examination and care for myself and/or dependents.Submit
