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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Anesthetics

Some of our recommended service providers

skin removal surgery, botox, skin services, filler, plastic surgery

Cohn Plastic Surgery https://www.cohnplasticsurgery.com/
Core Plastic Surgery https://www.coreandassociates.com/

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