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
top of page

Mental Health

In-person or Virtual Services

behavioral health, mental illness, therapy, psychology

Tiffany Dupree https://www.wholenesspsychiatry.com/

Jimel Gibbs https://www.renewedfocuswellness.com/

bottom of page