Step 1 of 12 - Patient Information

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Please complete the form below to begin the appointment scheduling process. Please note the form will take an estimated 10 minutes to complete.

To begin, please click here review the UAB St. Vincent's Joint Notice of Health Information Privacy Practices >>

I Accept Acknowledgement of Receipt of Joint Notice of Health Information Privacy Practices.
Name(Required)
Address(Required)
MM slash DD slash YYYY
Gender(Required)
Are you a post menopausal female NOT currently on hormone replacement therapy?(Required)
Are your pregnant?(Required)
Preferred Contact Number(Required)
Primary Care Provider(Required)
Primary Care Provider Address(Required)
MM slash DD slash YYYY
Are you interested in choosing a 199 Primary Care Provider?(Required)

Employer Information

Employer Address(Required)

Emergency Contact

Name(Required)

Insurance Data

Insurance Plan Address(Required)

Best Possible Dates for Service

MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY

Medical History

Please select any of the follow medical conditions that apply to you.

Family History

Has anyone in your family had the following conditions or treatments?

Present Symptoms

Please select any of the symptoms you're presently experiencing

Please list any current medications below

Allergies

Orthopaedic Issues

Please select and Orthopaedic issues you may be suffering from

Exercise

How often do you exercise each week?(Required)
Cardio(Required)
Weight Training(Required)
Should you not do Physical Activity?(Required)

Wellness

Satisfied with Weight(Required)