How do I get an appointment at the Civitan-Sparks Clinics?

If you would like to make an appointment at the Civitan-Sparks Clinics, and be placed on our waiting list, please complete the Patient Information Request Form.
Once the form is completed, save or print the form and submit it to us using one of the two options below.

1. Email the form to or

2. Mail the form to:  Attn: Shannon Bohannon
                                 CH 19; Suite 307
                                 1720 2nd Ave South
                                 Birmingham, AL 35294

Please access the Patient Information Request Form here.
Proof of legal guardianship is required at the time of the patient visit.

NOTICE: If I request records in electronic form, I understand that the records will be encrypted to help protect my privacy and the security of my health records and that I will be furnished with the information on how to access those encrypted records. UAB Health System is not responsible for the privacy and security of the electronic records in an email once they are received by the intended recipient. If I email information to my provider through unencrypted email, I understand that it is not a secure method of communication and UAB is not responsible for the security of those records.

If you need assistance completing the form, please call the number below. This information is used to schedule customized appointments for the appropriate clinics and specialists.

Please contact us if you have any questions.
1-205-934-5471 or 1-800-822-2472

If you or your physician require any medical records to be released, please complete the form below and submit to

Release of Medical Records Request Form 

In addition to doctor and other professional referrals, individual and family referrals are welcome. Individual and/or group health insurance and Medicaid are accepted.

If your child does not currently receive services, i.e., speech/language, occupational therapy, physical therapy and is suspected of having a developmental delay, please contact Child Find at 1-800-543-3098 for Alabama's Early Intervention Services (for children 0-3 years old), or the pre-school special education coordinator at your local school system for those children who are ages 3 and over but not yet in kindergarten.  If your child is in school but not receiving services, and you believe they should, please request your school system evaluate them.  Do not wait on your appointment with us.