Phone: (205) 733-1440

Fax: (205) 733-1442

Patient Information

_____________________________________________________________________________________________________

                                                                                                                                                                                            

Date: _____________________


Mr. Ms. Mrs. First Name ______________________________________   Last Name ____________________________________


Date of Birth _______/_______/_______                  Sex: M / F              S.S. # _________________________________________


Drivers License # _________________________________                       Marital Status ________________________________


How did you hear about us? _________________________________________________________________________________


Home Address ____________________________________________________________________   


City ____________________________________ State ________ Zip __________________


Emergency Contact Name _____________________________________    Phone # ___________________________________


Home # (_______)____________________   Work # (_______)____________________  Cell # (_______)____________________


Email Address __________________________________________________________________


Employer ______________________________________________________________________


Language _________________________________________           Race/Ethnicity ___________________________________



Signature __________________________________________    Date _______________________ 


Office Staff Signature _____________________________________________



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Complete Weight Loss and

Healthcare, LLC