Baton Rouge General Medical Center

Name*

First NameLast Name

Email

Date of Birth*

Date

Ethnicity*

Address

Address 1

Address 2

CityState

Zip Code

Primary Phone Number*

Secondary Phone Number

Marital Status*

Primary Care Physician*

Type of Procedure*

Due Date*

Date

OB/GYN*

Pediatrician*

Spouse Information (If applicable)

Spouse Full Name

First NameLast Name

Spouse Primary Phone Number

Spouse Secondary Phone Number

Insurance Information

Primary Insurance Provider*

Primary Insurance Holder*

Primary Insurance Holder Name*

First NameLast Name

Group Number*

Policy Number*

Primary Insurance Phone Number*

Secondary Insurance Provider (If applicable)

Secondary Insurance Holder

Secondary Insurance Holder Name

First NameLast Name

Group Number

Policy Number

Secondary Insurance Phone Number

Employment Information

Employer Name*

Occupation*

Employer Phone Number*

Employer Address

Address 1

Address 2

CityState / Province

Postal / Zip Code

Emergency Contact Information

Name*

First NameLast Name

Relationship to Patient*

Primary Phone Number*

Secondary Phone Number

Living Will

Religious Information

Religion

Church

If this is a medical emergency, call 911 immediately. If you have a medical question or are experiencing symptoms, please visit your nearest Urgent Care or Emergency Department. You are prohibited from listing health information, such as symptoms or medical history, as we cannot provide diagnosis or treatment by email. For your security, please do not use this form to share personal information, health information, social security numbers or credit card numbers. Instead, we recommend call your clinic and/or doctor directly. Information collected above may be used to schedule an appointment or to contact you.