Hannibal Clinic

573.221.5250 Patient Portal Login

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Patient Forms

Your provider may have asked you to complete one or more of the forms below. These forms help gather information that is vital to your success. If you have any questions, please contact your physician.

  • 24-Hour-Diet-Recall-Sheet.docx
  • Anti-Obesity-Medication-Consent-Form.docx
  • Eating-Behavior-Questionnaire.docx
  • New-Patient-Medical-History-Form.docx
  • STOP-BANG-Sleep-Apnea-Questionnaire.docx
  • Weight-Loss-Program-Consent-Form.docx
  • Why-I-Want-to-Lose-Weight-and-SMART-GOALS.docx

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  • 573.221.5250

Address

100 Medical Drive
Hannibal, MO 63401

Phone
573.221.5250

Hannibal Clinic | 100 Medical Drive Hannibal, MO 63401

In our rural health centers, no one will be denied access to services due to inability to pay and there is a discounted/sliding fee schedule available. It is the policy of Hannibal Clinic to provide service to all persons without regard to race, color, sex, national origin, handicap, religion, sexual orientation or age in compliance with 45 CFR Parts 80, 84, and 91 respectively. The same requirements are applied to all, and there is not distinction in eligibility for, or in the manner of, providing services. All services are available without distinction to all program participants regardless of race, color, sex, national origin, handicap, religion, sexual orientation or age. All persons and organizations having occasion either to refer persons for services or to recommend our services are advised to do so without regard to the person's race, color, sex, national origin, handicap, religion, sexual orientation or age.

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