First call our office to set up an appointment, (318) 387-9774. Then please take a few moments to fill out the form below. NOTE: Once you complete the patient information form, you will be presented with a patient history form to complete.

*We use a secure (SSL) server with the latest encryption technology offering the best possible protection against unauthorized access to your information.

Patient Information: First  MI Last SSN #   Date of Birth  Age Child  Single  Married  Divorced Address City State Zip Phone     Patient's Employer:     Employer Name Phone   IMPORTANT: If your spouse/parent is the primary card holder we need their date of birth and social security number in order to file insurance. Spouse/ Parent Information:     Name SSN #   Date of Birth  Spouse/Parent's Employer:     Employer Name Phone   Pharmacy Information:     Pharmacy Name Phone   Emergency Contact Information RELATIVE (OTHER THAN SPOUSE) WHOM WE MAY CONTACT IN EVENT OF AN EMERGENCY First  MI Last     Relationship Address City State Zip Phone     Referred By Referring Doctor Family Doctor Payment Information: ****PAYMENT IS EXPECTED AT THE TIME OF SERVICE***** Please do not assume that Dr. Marx is a provider for your insurance plan or that your insurance will be accepted and filed. ***I agree to pay any balance due at the time of service including co-insurance and co-pays.***   Payment will be made by:    Check  Cash  Credit Card   FINANCIAL AGREEMENT AND AUTHORIZATION FOR TREATMENT I authorize treatment for the person named above and agree to pay all fees and charges for such treatment at the time of service. Once insurance has paid, I agree to pay all balances for me and my family members promptly upon receipt of statement, unless credit arrangements are agreed upon in writing. Charges shown by statements are agreed to be correct and reasonable unless protested in writing within thirty (30) days of billing date. In the event my account is turned over to collections or legal action should become necessary to collect an unpaid balance due for medical services rendered to me or my family, I/we agree to pay collection costs and/or reasonable attorney's fees or other such costs as the Court determines proper. It is agreed that payments will not be delayed or withheld because of any insurance coverage or pending claims, and all proceeds of insurance are assigned to this office where applicable, but without their assuming responsibility for the collection thereof. A copy of the assignment is as valid as the original. I authorize the release of any medical or other information necessary to process insurance claims and also authorize payment of medical benefits to be paid to Dr. Don Marx. IMPORTANT: Submitting this form does not constitute your agreement and authorization. You will be provided a hard copy to sign when you come in for your appointment.