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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Schedule your service

Book this visit after an initial consultation visit has been completed.

Check out our availability and book the date and time that works for you

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