- Please complete the forms below
- Please save and email to: [email protected] or print and fax to: (318) 352-9818
- If you have any questions or problems filling out the forms you may reach us at: (318) 352-9595
New Patient Paperwork
- New Patient Paperwork for GYN Patients
- New Patient Paperwork for Pregnant Patients
- New Patient Paperwork for NSU Student GYN Patient
OB Patient Paperwork
- Authorization to Disclose Medical Records (To Send)
- Authorization to Disclose Medical Records (To receive)
Make a Payment Options
- Mail checks to 627 Bienville Circle, Natchitoches, LA 71457. Make checks payable to Natchitoches Women’s Care. Please include payment stubs and write your account number on the memo line of the check.
- Pay by credit card using your Visa, Mastercard, American Express or Discover card by phone: 318-352-9595 .
- https://payments.sonichealthcareusa.com/index.aspx?co=CPL 20% Discount from CPL
Patient Support Group http://www.merckmedicus.com/pp/us/hcp/hcp_patient_support.jsp?WT.mc_id=H17VD
Central Louisiana Breastfeeding Coalition, Inc. www.cenlabreastfeeding.org
318-451-1929 or 318-561-7805
If you are interested in enrolling in one of our programs, OR learning about our Coalition, please fill out the information below and leave with the receptionist or nurse.
To be eligible for CLBC programs, applicants must reside in Avoyelles, Natchitoches, or Rapides parish. Call for more information.
My Patient Portal