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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Fitness

Gyms and Personal Trainers

exercise, activity, work out, weight lifting, resistance training

Hoover:
Thompson Fitness https://tfit205.com/

Homewood
Gauntlet https://gauntletfit.com/

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