Telehealth - Body by Yashi

To ensure that we have a wonderful experience, please complete this form prior to your session. Recording of any kind is not permitted.

Name *

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Address *

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Do you have any allergies to medication? *

List all drug allergies *

Do you have any pre-existing health issues/diseases? if yes, please explain *

Name of Surgeon *

Date of Procedure(s) *

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Date

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Chief Complaint: Please give a brief description on the nature of this visit *

ALL SALES ARE FINAL: Payment is due at time of booking. There are no refunds or exchanges on any products or services. Recording is not permitted. *

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