Medical Weight Loss - 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 have been informed that I can use my insurance at Quest Diagnostic Labs for lab testing or pay out of pocket. I have been informed that I am financially responsible for my medical care and lab work. *

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 (synchronous or asynchronous) 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

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Height *

Weight *

Are you allergic to any drug? *

No drug allergies (NKDA)
Yes

Do you have a personal or family history of any of the following? *

Multiple Endocrine Neoplasia syndrome
Thyroid Cancer
Pancreatitis
I do NOT have any of those conditions

Weight Loss Progress Photos (Optional)

Click or drag files to this area to upload. You can upload up to 6 files.

Is there any additional information you would like to share with the medical provider today? (Optional)

FAQ

FAQ

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