• Whole Body DEXA Scan Intake Form

    Please complete this form to provide your information, review important terms, and pay for your DEXA scan if you are not redeeming your Membership Free Annual Scan. After submission, you'll be redirected to schedule your appointment.
  • Are you currently a member of Yakima Men's Clinic and on a cash-pay membership?
  • Are you redeeming your free annual scan or have you already used your free annual scan and would like to pay for an additional scan?
  • Sex
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Have you previously had a DEXA scan performed?
  • Do you have any metal/hardware in your body?*
  • Any problems with lying flat?*
  • Have you had any fractures past the age of 40? (excluding on your skull, hands, or feet)*
  • Have either of your parents fractured their hip in their lifetime?*
  • Are you currently a smoker? (Tobacco, Marijuana, or Vaping)*
  • Have you ever taken oral Prednisone for 3 months or longer in your lifetime?*
  • Have you ever been diagnosed with Rheumatoid Arthritis?*
  • Have you ever been diagnosed with 'Secondary Osteoporosis'?*
  • Do you drink more than 3 drinks of alcohol daily, on average? (1 drink = 1.5 oz of liquor, 4 oz of wine, 12 oz of 5% beer)*

  • Important Information (Please Read Before Paying)

  • By submitting form you are stating that you understand and agree to the following:

    • This is not a medical consultation.
    • This scan is provided for informational, fitness, and general health tracking purposes, and is not an official diagnostic medical study.
    • This is not billed to insurance.
    • Cancellation policy applies.
    How you will receive results:
    Results will be available to you on the fittrace app. By agreeing to the terms and conditions, you agree to receive your results electronically via a Fittrace account which will be created automatically. After your scan we will show you how to access the app, which can be done on your phone or an internet browser.

    Your results will be available via the app. There is no doctor consultation. However, if you want a doctor's consultation you may purchase one for $100. If you want this, simply check the box "15 minute Physician Consultation".

    Cancellation Policy Key Points:

    • Rescheduling is free up until 24 hours before the appointment.
    • There is a $20 fee to re-schedule within 24 hours of the appointment.
    • Cancellations more than 24 hours before the appointment are eligible for a full refund.
    • Cancellations within 1–24 hours are eligible for a 50% refund.
    • Cancellations within 1 hour of appointment time and no-shows will not receive a refund.
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  • Payment Information*

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        DEXA Scan

        Option of purchasing 1 scan or selecting special discounted bundling pricing.

        $120.00$120.00
        Item subtotal:$0.00$0.00
          
        15 minute Physician Consultation

        You will be provided with an easy to read report but if you would like the extra consultation to be able to ask questions or get a better understanding then select the Physician Consultation.

        $100.00$100.00
        Item subtotal:$0.00$0.00
          
        Total
        $0.00$0.00
        Payment Methods
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