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eVisit Registration

EXPRESS WEIGHT LOSS CLINIC

Non-surgical medical weight management

eVisit Patient Registration

Notice: A $25 deposit is now required to reserve an appointment time. Payment information will be collected at the end of the form and the payment must be successful prior to scheduling a date and time for an appointment.

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.

eVisit Form

Patient Information

Patient Name *
Date of Birth *

Patient Information

Gender *
If you wish to receive any information or promotions from Express Weight Loss Clinic: *

Medical History

Current/Past Medical History - Check all that apply: *
Heart Attack Date *
Stroke Date *
Past Surgical History - Check all that apply: *
Social History - Check all that apply: *
Review of Symptoms - Check all that apply: *
Eating Habits - Check all that apply: *
Physical Activity - Check if applicable:

Non-surgical medical weight management

EXPRESS WEIGHT LOSS CLINIC

Acknowledgement: *
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Use your mouse or finger to draw your signature above
I am 18 years of age or older *

By signing below, I do hereby consent to any medical care and/or treatment administered by the clinician(s) at Express Weight Loss Clinic (EWLC). I understand that EWLC, as well as other clinicians, cannot anticipate whether my child will experience adverse reactions, side effects, or allergic reactions, after receiving any medication(s) EWLC prescribes or administers via injections. I understand that such reactions can occur to anyone, with any medication, at any time, and that the prescribing clinician and EWLC is not at fault for such reactions. I understand that if my child experiences any adverse reactions, side effects, or allergic reactions from any medication(s) that they receive from EWLC, then it is my responsibility to discontinue my child's use of the medication immediately, seek advice, and to have my child evaluated by their PCP and/or Emergency Medical Providers. In the event that my child experiences a medical emergency while being treated at EWLC, I consent to the administration of medical life saving measures determined by the clinician to be necessary for the welfare of my child, while waiting for Emergency Medical Services to arrive on scene during said emergency.

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Use your mouse or finger to draw your signature above
Guardian's Printed Name *

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.

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? *
Do you have your government issued driver's license or ID? * You will be required to show identification during your scheduled consult time.
Do you have your form of payment? *
Visa, Mastercard, AMEX, Discover
Do you have your scale? *
Do you have your automatic (electronic) blood pressure cuff? *
Do you have your measuring tape? *

This item is recommended for your eVisit.


Feel free to follow the links below for low-cost option measuring tapes. (links will open in a new tab)


https://www.amazon.com/shop/expresshealthsystems

Do you have a web cam or video enabled smart device? *
Which device will you be using for the eVisit? *

You will receive the meeting invitation via email prior to your scheduled eVisit. You will be automatically prompted to download and install the Zoom App when attempting to join a meeting.

Android users will be required to have the Zoom app installed on their device prior to attempting a connection to the video session invitation. The Zoom App can be found here Android Zoom App

iOS users will be required to have the Zoom App installed on their device prior to attempting a connection to the video session invitation. The Zoom App can be found here iOS Zoom App

This item is required in order to receive online eVisits from Express Weight Loss Clinic. Please return when you have these items available.


Click here to exit the eVisit registration and return to our eVisits Page

This item is required in order to receive online eVisits from Express Weight Loss Clinic. Please return when you have these items available.


Click here to exit the eVisit registration and return to our eVisits Page


Also, feel free to follow the links below for low-cost option scales. (links will open in a new tab)


https://www.amazon.com/shop/expresshealthsystems

This item is required in order to receive online eVisits from Express Weight Loss Clinic. Please return when you have these items available.


Click here to exit the eVisit registration and return to our eVisits Page


Also, feel free to follow the links below for low-cost option blood pressure cuffs. (links will open in a new tab)


https://www.amazon.com/shop/expresshealthsystems

Payment Information

Enter your card information: *

Click submit below to be routed to our 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