Prescription Request - Body by Yashi

Terms of Use: I confirm that I am age 18 or older. I understand that I must be physically located within the state of New York at the time of treatment. * *

I agree

Informed Consent and Authorization to Administer Treatment * I hereby authorize Body by Yashi's medical team to review my medical history and administer medical services to me, the patient, via telemedicine. I hereby authorize Body by Yashi to prescribe an alternative drug if my preferred or selected medication is potentially harmful, unsafe, controlled, dangerous, interacts with my existing medication or result in adverse drug reaction I have been informed that telemedicine services are reserved for mild to moderate complexity medical needs. I understand that Body by Yashi will cancel and refuse to accept patients with complex or life-threatening conditions. I understand that Body by Yashi will provide online medical services based on the medical history I provide, in the absence of a physical examination. I hereby agree to take full responsibility for damages or harm that may occur from submitting inaccurate, incomplete or misleading information. I understand the risk of misdiagnosis associated with utilizing telemedicine due to the absence of a physical examination or an in-personal evaluation. I agree to indemnify and hold Body by Yashi and its employees harmless from any loss, damages, liability, legal liability and expenses resulting from withholding or non-disclosure of my medication or any other vital medical information. *

I agree

Reason for this visit? *

Order a new prescription
Refill a prescription

Name *

First

Last

Date of Birth: *

Gender *

Female
Male

Shipping Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Upload Drivers License *

Click or drag a file to this area to upload.

State ID

Are you allergic to any food or medications? *

No known allergies (NKA)
Yes

What are you allergic to and what reaction do you have when you take it?

Are you currently taking any medications? This includes OTC (over the counter) medications, vitamins or supplements. *

List all medications that you're currently taking. *

Have you experienced any significant side effects with prescription? *

STOP! Contact Body by Yashi for re-evaluation

Do you have any underlying medical conditions? *

No medical history
Heart disease
Hypertension
Liver disease
Kidney disease
Diabetes
High cholesterol
Thyroid disorder
Psychiatric condition
HIV/AIDS
Other Condition

Type of heart disease *

Coronary Artery Disease (CAD) or heart attack
Heart Valve Disease
Arrhythmias or abnormal heartbeat
Heart Failure or CHF
Congenital Heart Disease
Cardiomyopathy (Heart Muscle Disease)
Pericardial Disease
Other

List other heart conditions that you have *

What's your average blood pressure reading? *

Normal (Less than 140/90)
Elevated (Less than 160/100)
Uncontrolled (Over 160/100)

Type of liver disease *

Type of kidney disease *

Kidney stone
Polycystic Kidney Disease
Kidney infection or cyst
Nephritis or nephropathy
Kidney cancer
Elevated creatinine or low GFR
Solitary or Single-functioning Kidney
Other

List other kidney disease *

How stable or controlled is your diabetes? *

Well controlled (Glucose below 150 or Hba1c less than 8)
Somewhat controlled (Glucose below 200 or Hba1c less than 9)
Uncontrolled Diabetes (Glucose over 200 or Hba1c over 9)

Last thyroid test *

Normal TSH level in the last 12 months
Hypothyroidism (Elevated TSH or low T4 or T3)
Hyperthyroidism (Low TSH or elevated T4 or T3)
No thyroid lab test in the last 12 months
I have symptoms of abnormal thyroid disorder

Select applicable psychiatric condition *

Depression
Anxiety
Panic disorder
Bipolar or mood disorder
Schizophrenia or psychosis
PTSD
Eating disorder
OCD
Other

List other psychiatric conditions *

List any other medical conditions that you may have *

Are you pregnant? *

STOP! Some medications should be avoided during pregancy

Are you breastfeeding? *

STOP! Some medications should not be used while breastfeeding

(Not Applicable) Continue To Next Page

Add Photos (Optional)

Click or drag files to this area to upload. You can upload up to 4 files.

Refund Policy Terms: I understand that all sales are final. I have been informed that it is my responsibility to handle prescription medication with care and store it in a safe environment. *

I agree

Dermatology

GLOW (Kojic Acid 5%/ Hyaluronic 0.5%/ Ascorbic Acid 2%) 30g Cream – $75.00
MIRACLE (Hydroquinone 4%/ Retinoic Acid 0.1%/ Kojic Acid 4%) 30g Cream – $80.00
CORRECTOR/ (Hydroquinone 6%) 30g Cream – $85.00
CORRECTOR PLUS (Hydroquinone 10%) 30g Cream – $95.00
CORRECTOR MAX (Hydroquinone 12%) 30g Cream – $100.00

Shipping Method *

Total

$0.00

Square *

Card

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FAQ

FAQ

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