New Patient Intake Form

Please complete the intake form below to the best of your ability. This form covers many areas including your personal information, health history, eating and exercise habits, contact information for the individuals close to you, information about your health care providers and information about your insurance. 

Before you begin, please make sure you have these materials accessible to you. Once you are ready to begin, please allow approximately 30-45 minutes of your time to complete the form as fully as you are able.

If you prefer, to print and download the form to complete and mail or upload below.

For convenience, we recommend that the Patient Intake form is completed on a computer desktop. If you prefer to use your mobile device, you can use the Adobe Fill & Sign app, which can be downloaded from your app store. See instructions below if you have an iPhone and use the web browser Safari.

iPhone Safari form instructions

Steps to complete form:

1. Download the form to your phone
2. Open the form in the Adobe app
3. Complete the form
4. Save it to your device
5. Load the completed form into the form below

You can also mail form to: MercyOne Cedar Falls Weight Loss Center & Bariatric Surgery 515 College Street Suite 2800 Cedar Falls, Iowa 50613