EWLC eVisit Registration

eVisit Registration

EXPRESS WEIGHT LOSS CLINIC

Non-surgical medical weight management

eVisit Patient Registration

Deposit FAQs

Why are we collecting a deposit?

Once you make an appointment that date and time is blocked for you alone. Another person cannot book an appointment for the same date and time that you have reserved. Once you have made a reservation, we must schedule staff members to be available to see you at that time. If at the last moment you fail to show up for your appointment, no other person has time to fill your date and time reservation, yet we still incur staffing cost. This is not fair to other patients that would have wanted to be seen during the appointment date and time that you reserved. It also creates an unfair financial burden to our company.
What happens to my deposit?

If you show up for your scheduled appointment, your deposit will be applied towards your visit's expense.
Under what circumstances would I lose my deposit?

If you fail to show up to your scheduled appointment date and time, you will lose your deposit. If you fail to have ALL of the necessary equipment (Photo ID, Digital Blood Pressure Cuff, and scale), then you forfeit your deposit. Please note that we monitor prescription controlled substances and that we CANNOT prescribe appetite suppressants if you are actively taking any medications for ADD/ADHD.
Under what circumstances can I get my deposit refunded to me?

If you cancel or reschedule your appointment date and time more than 72 hours prior to your reserved date and time appointment, your deposit will be refunded to you or applied towards your new scheduled appointment date and time. If, however, you reschedule or cancel your appointment three times in a row, you will lose your deposit regardless of how far out you cancelled or rescheduled the appointment.

Please select the state of the pharmacy your script will be sent to: *

Selecting a state serves as an acknowledgement that I will be located in the selected state at the time of my eVisit.

Regulations prevent prescribing appetite suppressants via telemedicine in the state that you selected. We apologize for any inconvenience.

Patient Information

Patient Name *

First Name (as appears on License/Identification)

Last Name (as appears on License/Identification)

Middle Name (optional)

Maiden Name (if applicable)

Date of Birth *

Please fill in your information then click continue.

Patient Information

Address * Street Address

Apt #/Suite/Other (Optional)

City

State

ZIP Code

Gender * Male Female

Email Address *

Phone Number *

If you wish to receive any information or promotions from Express Weight Loss Clinic: No Thank You Email Text (carrier charges may apply) Mail

Medical History

Medical History Other (Please explain):

Heart Attack Date *

Stroke Date *

Past Surgical History - Check all that apply: *

Past Surgery Other (Please explain):

Social History - Check all that apply: *

None Cigarettes Smokeless Tobacco Alcohol Consumption Illicit Drugs:

Alcohol Consumption Frequency: *

Infrequent Social Drinking Frequent Small Amounts Frequent Large Amounts

Illicit Drugs: *

Review of Symptoms - Check all that apply: *

None Swelling Fatigue Skin, Hair, or Nail Problems Excess Weight

Eating Habits - Check all that apply: *

None Large Portions Sweets/Snacks Carbonated Drinks

Allergies to Medications - Please List:

Current Medications - Please List:

Physical Activity

Do you exercise? * Yes No

How many days per week? * 1 2 3 4 5 6 7

How long do you exercise? * 30 minutes 30-60 minutes > 60 minutes

What kind of exercise do you do? *

Walking Jogging/Running Mixed cardio Swimming Other

Other exercise:

Non-surgical medical weight management

EXPRESS WEIGHT LOSS CLINIC

Acknowledgement: * By signing below, I agree to the Terms and Conditions of Service

Patient Signature *

Use your mouse or finger to draw your signature above

Clear

We are currently accepting Patients into our Virtual Waiting Room. Would you like to be put into our Virtual Waiting Room or Schedule at future date and time? * Virtual Waiting Room Schedule Future Date & Time

Prepare for eVisit Checklist

Please make sure you use the calendar scheduler after you submit the eVisit form. If you do not schedule an appointment you will not be seen. Thanks.

Please make sure you are prepared with the following items prior to your scheduled eVisit time:

Government-issued driver's license or ID
Form of payment (Visa, Mastercard, AMEX, Discover)
Scale
Electronic blood pressure cuff
Web cam or video-enabled smart device

I understand

Payment Information

Enter your card information: *

Cardholder Name

Card Number

Expiration Date

Security Code

Click submit below to be routed to our NEW scheduling page. You have to schedule using the calendar to be seen via eVisit

For downloadable versions of these forms and waivers, please visit our Forms Page

eVisit Registration

Deposit FAQs

eVisit Form

Regulations prevent prescribing appetite suppressants via telemedicine in the state that you selected. We apologize for any inconvenience.

Patient Information

Patient Information

Medical History

Physical Activity

Prepare for eVisit Checklist

Payment Information

Click submit below to be routed to our NEW scheduling page. You have to schedule using the calendar to be seen via eVisit