Services
Medical Care
Weight Loss
Post Op Care
IV Therapy
Mobile Sprinter
Policies
Training
Shop
Contact Us
Services
Medical Care
Weight Loss
Post Op Care
IV Therapy
Mobile Sprinter
Policies
Training
Shop
Contact Us
$
0.00
0
Cart
FAQ
FAQ
$
0.00
0
Cart
Services
Medical Care
Weight Loss
Post Op Care
IV Therapy
Mobile Sprinter
Policies
Training
Shop
Contact Us
Services
Medical Care
Weight Loss
Post Op Care
IV Therapy
Mobile Sprinter
Policies
Training
Shop
Contact Us
Please enable JavaScript in your browser to complete this form.
–
Step
1
of 7
Name
*
First
Last
Date of Birth:
*
Next
Reason for this visit?
*
New prescription
Refill Prescription
Previous
Next
Gender
*
Female
Male
Patient Address
*
Address Line 1
Address Line 2
City
— Select state —
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
*
Email
*
Previous
Next
Upload Government Issued ID (Front)
*
Drag & Drop Files,
Choose Files to Upload
Previous
Next
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 authorize the medical providers at Body by Yashi to review my medical history, provide telehealth weight loss services, and prescribe medications when medically appropriate. I understand that treatment recommendations are based on the information I provide without an in-person examination, and I agree to provide complete and accurate medical information. I understand that my requested medication may not be prescribed if it is unsafe or medically inappropriate, and an alternative treatment may be recommended. I also understand that telehealth is not a substitute for emergency medical care and agree to seek immediate medical attention or call 911 if I experience severe or worsening symptoms.
*
I agree
Refill Request
*
Increase dose
Continue with current dose
Previous
Next
Date / Time
*
Date
Time
Telehealth
*
Initial (New Patient) –
$99.00
Follow-up (Refill Request) –
$49.00
PayPal Commerce
*
Card Number
Expiration Date
Security Code
Card Holder Name
Total
$0.00
Previous
Next
Previous
Submit