Phone: (225) 769-4044

New Patient Registration Form

If you are new to The Baton Rouge Clinic, you can fill out this form at your convenience, and submit it to our office. We will review your information and enter it into our database. Our staff will send you a confirmation once your form has been received and processed.

You must fill out this online form at least twenty four hours prior to your appointment. If your appointment is less than twenty four hours away, please fill out a registration form upon your arrival in our office.


Responsible Party
Name:*
Home Phone:* () -
Address:*
City:* State:
Zip:*
Employer:
Employer Phone: () -
Emergency Contact
Name:
Phone:
Patient
Name:*
Date of Birth:
Gender:
Relationship to
Responsible Party:*
Social Security Number:
Employer:
Employer Phone:
Primary Care Physician:
Marital Status:*
Spouse Name:
Spouse Employer:
E-Mail Address:
Have you ever been to the clinic?
Yes No
Primary Insurance
Effective Date:
Company Name:
Address:
Company Phone:
Group Number:
Policy Number:
Subscriber:
Subscriber's SSN:
Patient Relationship
to Subscriber:
Secondary Insurance
Effective Date:
Company Name:
Address:
Company Phone:
Group Number:
Policy Number:
Subscriber:
Subscriber's SSN:
Patient Relationship
to Subscriber:

- Click the Register button once to register.

Note: A red asterisk ( * ) denotes required fields.