Patient Registration Form

Name: Wendy Waguespack,OD
Address: 7932 Picardy Avenue, Suite A, Baton Rouge, LA, 70809, US
Telephone: 225-767-8495
Price range: $000 - $300

To print and fill out the New Patient Paperwork, click here

Bring it at your next visit.

You can also send us your insurance card information over the internet with the form below.

New Insurance Card Form

Patient Information
Name*
Prefix First Last Suffix
Phone Number*
Please provide a telephone number, with area code, so we can contact you.
Email Address
Please provide us your email address.
Primary Insurance
Please bring all insurance cards with you to your appointment.
Insurance Company Name
Insurance Company Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insured's Name*
First Last
Identification Number*
Group Number*
Insured's Date of Birth
Date Format: MM slash DD slash YYYY

(optional)
Patient's Relation to Insured
Secondary Insurance
Do you have secondary insurance?
- Yes
- No
If you have coverage through another plan/organization, please fill in the details below.
Insurance Company Name
Insurance Company Phone Number
Insured's Name
First Last
Identification Number
Group Number
Insured's Date of Birth
Date Format: MM slash DD slash YYYY
Patient's Relation to Insured
Additional Details
Please add anything else from your card(s) that we didn't state above.
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

Upload Insurance Cards

Upload an image of your insurance cards or driver's license here.

Dry Eye

Scleral Lenses

Patient Registration Form

Bring it at your next visit.

New Insurance Card Form

Patient Information

Primary Insurance

Secondary Insurance

Additional Details

Wendy Waguespack,OD