Patient Information Sheet

Bariatric Patient Information Sheet

Name:
Address:
Home#:
Work#:
Cell Phone#:
Sex:
Height:
Weight:
Date of Birth:
Primary INS:
Secondary INS:

Patient Agreement Terms & Conditions You understand and agree that, despite reasonable efforts to protect the privacy of health information received and maintained by us, use of the Service is by communication using e-mail over the Internet. ECU Physicians cannot guarantee the confidentiality or security of communications with the Service while over the Internet. Unauthorized people may be able to intercept, read, and possibly modify your communication while in transit to and from ECU Physicians as part of this Service.

I have read and agree to the Patient Agreement: