Book An Appointment: Weight Loss

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We’re actually not in {state} yet 🤦‍♂️

But we're working hard to get there! Click NEXT and leave us your contact information and we'll let you know when we launch in {state}.
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What’s your Preferred Availability?Select all the days of the week and all the times of day that you might be available for a consultation. (Select all that apply.)
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Telehealth Informed Consent* This field is required.You are being offered healthcare services using “telehealth” technology. This form explains your rights, the risks and benefits of telehealth, and your options. Please read it carefully before signing. If you have any questions, please feel free to call our office at 888-959-7299. 1. Nature of Telehealth Telehealth involves the use of electronic communications (audio, video, or other digital means) to deliver medical or mental health care when you and the provider are not in the same physical location. Services may include consultation, diagnosis, treatment, follow-up, and patient education. 2. Provider Disclosure You will be informed of the name, credentials, and location of your provider before or at the start of the session. All persons present during the session, including trainees or assistants, will be identified and you will have the right to request their exclusion. 3. Patient Rights You may request an in-person appointment instead of telehealth, when reasonably available. You may withdraw consent or stop telehealth care at any time but prior to future visits, a new consent to treat will have to be authorized. You have the right to access your medical records resulting from a telehealth encounter, as provided by law. 4. Risks and Limitations Technology may fail or be interrupted (e.g., poor connection, hardware/software malfunction). Security protocols may fail, potentially exposing personal information. Telehealth may not be as effective as in-person visits for certain conditions. If a telehealth visit is deemed clinically inappropriate, you may be asked to schedule an in-person follow-up. 5. Privacy and Confidentiality All communications will comply with HIPAA and applicable privacy laws. Security measures will be in place to protect your information. You are responsible for ensuring privacy on your end (e.g., secure location, using your own device). 6. Billing and Insurance Telehealth services shall be paid out-of-pocket. 7. Emergency Situations Telehealth is not appropriate for emergency medical conditions. In case of an emergency, call 911 or go to the nearest emergency room. Consent and Acknowledgment By selecting "I Consent" below, I confirm that: • I have read and understand the information above. • I have had the opportunity to ask questions, and they have been answered. • I voluntarily consent to receive healthcare services via telehealth.
I Consent
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⚠️ Telehealth Consent Needed

In order to book a telehealth appointment, we'll need you agree to our Telehealth terms. To continue, click Previous below and choose “I Consent”.

If you have any questions or would like help reviewing the form, feel free to call us at 888-959-7299, our team is happy to assist you.
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Signature* This field is required.Sign here:
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Referral Source
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Referral Network Location
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Most Recent Appointment at this Location
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Referral URL
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Referrer Name
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Referring Provider Name
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Referring Provider ID
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Practice
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Type
Should be Empty:

We’re actually not in {state} yet 🤦‍♂️

⚠️ Telehealth Consent Needed