Patient Intake Forms – Texas Center for Bariatrics & Advanced Surgery

Name

This field is for validation purposes and should be left unchanged.

Name & DOB

First Name*

Last Name*

Date of Birth*

Preferred Name

What would you like us to call you?

Address

Street Address*

Apartment, Suite, Unit

City*

State*

ZIP Code*

Contact Info

Mobile Phone*

Home Phone

Email Address*

Preferred Contact Method

Employer Info

Employer Name

Occupation

Identification Verification

Your insurer requires these to verify coverage. They are transmitted over an encrypted connection and are never shown back to you.

Social Security #

Driver's License #

Sex

Male

Female

Marital Status

Emergency Contact

Emergency Contact Name*

Relationship to Patient*

Emergency Contact Phone*

Alternate Phone

How did you hear about our practice?

Primary Care Physicians

Please list all current physicians who are involved in your health care.

Who is your Primary Care Physician (PCP)?

PCP Phone Number

Please enter a valid phone number.

Other Physician Name

Specialty

Phone Number

Do you have an additional physician to include?

Yes

No

Insurance Information

Is insurance carried by someone other than the patient?

Yes

No

Primary Insurance Company

Insurance Phone Number

Policy Holder Name

Policy / Member ID

Secondary Insurance Company

Insurance Phone Number

Group Number

Policy Holder Date of Birth

As the responsible party, I agree that all the charges that are not directly paid by my insurance will be my responsibility.

Name of Signee

First Name*

Last Name*

Date*

Medications & Allergies

Current medications and dosages

Include prescriptions, over-the-counter medicines, vitamins and supplements.

Allergies

Include the reaction, if you know it. Enter “None” if you have no known allergies.

Lifestyle

Do you currently use tobacco or nicotine products?

Yes

No

I quit within the last 12 months

How often do you drink alcohol?

How often do you exercise?

Consent & Authorization

I certify that the information I have provided is complete and accurate to the best of my knowledge. I authorize The Center for Bariatrics to use this information to evaluate my candidacy for treatment and to contact me about my care.

Type your full name as your electronic signature*