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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​Phone: (205) 769-6032

Fax: (205) 769-6031

Complete Weight Loss and

Healthcare, LLC