Birmingham Bariatric Care

New Patient Intake Form

Please complete this form before your appointment. Your information is confidential and protected under HIPAA guidelines.

Patient Information
Insurance Information
Reason for Visit
Medical History

Check all that apply:

Current Medications & Supplements
Lifestyle Information
Consent and Acknowledgment
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Initial Consultation

The initial session involves a comprehensive assessment of a person's overall health and medical history. This includes reviewing conditions like obesity, diabetes, hypertension, or heart disease, as well as any past surgeries or treatments. It's important to find out where you are and where you want to be. From that point, we can create a game plan for your path to success. 

Medical Follow Up Visit

This visit is a follow up visit after an initial assessment has been completed. This may be a medication management, physical exam, lab visit, or weigh in with a licensed provider.

Store

Welcome to our link store! Explore a wide range of premium supplements and health products designed to support your wellness journey. Whether you're looking to boost energy, improve fitness, or enhance overall well-being, we have linked some of our favorite products. Shop now and start prioritizing your health today!

Community

Welcome to our community links! Our service is deeply rooted in community, offering accessible, educational, and supportive programs that promote healthier living beyond our services. Through networking, partnerships, and outreach, we empower individuals and families with practical tools for nutrition, fitness, and mental well-being. By meeting people where they are—whether in local organizations, workplaces, or virtual settings—we’re helping to build a stronger, healthier community for everyone.

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