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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Bariatric Surgery

Bariatric Surgeons

weight loss surgery, bariatric surgery, gastric sleeve, gastric bypass, endoscopic sleeve, gastrectomy

Advanced Surgeons, PC https://www.advancedsurgeonspc.com/
Obesity Control Center https://www.obesitycontrolcenter.com/

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