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2617 Hwy 31 South Pelham, AL 35124

Patient Information Form

Completing and submitting the following information prior to your appointment will help us make your visit more punctual and thorough.

Insurance Information

Medical History

To help our office better serve your specific needs, please check all that apply. Please leave boxes unchecked for a NO answer.

General Health Condition

Family History

Currently taking medication(s) - prescription and/or over the counter

Drug Allergies