Waggoner Pediatrics Insurance Card Image Portal

Insurance Card Image Upload
Please upload a copy of the front and back of your insurance card, then press submit.

(You can use your cell phone to take a picture of each side.)
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Please attach a photo or scan of the FRONT side of your insurance card. *

Select Insurance Card Image

Cancelof
Please attach a photo or scan of the BACK side of your insurance card. *

Select Insurance Card Image

Cancelof
Should be Empty:

Insurance Card Image Upload