The Office of
Dr. Richard Waguespack


Personal Information

Your Email Address:

First Name: Middle Name: Last Name:

Social Security#: Date of Birth: Gender:

Marital Status:

Street Address:

City: State: Zip Code:

Home Phone: Emergency Phone:

Name of Relative not living with patient: Phone:

Patient's Occupation:
Patient's Employer:
Patient's Work Phone:

Name of Patient's Spouse: Spouse's Employer:

Spouse's Phone:

If Patient is a MINOR, Please complete the following:

Mother's Name: Mother's Employer:

Mother's Date of Birth: Mother's Social Security Number:

Mother's Work Phone:

Father's Name: Father's Employer:

Father's DOB : Father's Social Security Number:

Father's Work Phone:

Father's Address:

Have you or anyone in your family been a patient of the Doctor?

If so, Who?

Your Relationship to this person:

Whom may we thank for referring you to our office?


Insurance Information:

Payment for services rendered is to be made as follows:
I request that payment of authorized insurance benefits be made to RICHARD W WAGUESPACK, MD, PC for any services or items furnished to me by the physician or supplier. I authorize the practice to release to the Health Care Financing Administration (HCFA/CMMS), my insurance carrier, and/or its agents appropriate information needed to determine these benefits or the benefits payable for related services, in accordance with HIPAA guidelines. Release of other information requires specific release authorization. I am financially responsible for appropriate deductibles, copayments, and non-covered items (which have been explained to me from information supplied by my carrier). If this account has to be turned over to an attorney due to delinquency or non-payment, I will be responsible for all costs of collection including the court costs and reasonable attorney fees.


Name of Insurance Company:

Insurance Company Phone Number (Back of Card):

Name on Card / Policy Holder:

Policy Number:

Group Number:



Name of Second Insurance Company (If Applicable):

Insurance Company Phone Number (Back of Card):

Name on Card / Policy Holder:

Policy Number:

Group Number:


  Select Yes to agree to the Insurance and Payment Information statement of the office of Dr. Waguespack. Select No if you do not wish to register online.

  Select Yes to authorize Dr. Richard Waguespack to render treatment to myself or persons that I am responsible for in order to register online. Select no if you do not wish to register online.

DISSEMINATION OF MEDICAL INFORMATION:
To whom may we, as your health care provider, release information about your medical condition(s)? Please include relationship information such as parent, spouse, etc for each person.

  Do not share my medical information
 I agree to Share my medical information with the following:




Privacy Statement

In order to register online, you must agree to the terms of our Privacy Statement . Please read and print this out for your records.

  Select yes to agree to the Privacy Statement of the Office of Dr. Waguespack.

Name of person completing this form:



By clicking the SUBMIT button, you are agreeing to send this information
electronically to the Office of Dr Waguespack. The office of Dr Waguespack
assumes no liability for the transfer of this information.

All online registrations are subject to approval and not considered complete until an actual signature is obtained at first appointment