MedClub TeleHealth Waiver

Step 1 of 5

Current Conditions(Required)

Why are you interested in starting/continuing this therapy?

Specify Condition

Type Condition/Diagnosis Here

BMI (Body Mass)

BMI is a simply calculation that determines if a person is Underweight, Healthy, Overweight, or Obese.

My BMI is over 27

My BMI is between 22-27

I do not know my BMI

Biological Sex(Required)

Biological Sex Assigned at Birth

Male

Female

Pregnant/Breastfeeding

I am NOT currently pregnant or breastfeeding

I am currently pregnant

I am currently breastfeeding

Name(Required)

First Last

Date of Birth(Required)

Input Date of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Upload Photo ID Copy

Please upload a picture of your Drivers License or Photo ID - Must be 18+

Max. file size: 128 MB.

ID Number

If you are unable to upload a photo of your ID you may supply us with the ID numbers and state of issuence.

Telemed Intake Waiver