New & Returning Health Profile (updated 10/16/2020)

Name *

First

Last

Your Preference of 1st Visit *

Telehealth Video/Phone Appt (please allow for 24-48 business hrs processing time to review your records)
Regular IN-PERSON office appt (please allow for 24-48 business hrs processing time to review your records)

Please let us know if you prefer a telehealth visit or an in-office visit. For in-person appt, you may book online via http://www.elevationweightloss.setmore.com

Patient's Desired Mailing Address *

Address Line 1

City

State

Zip Code

PLEASE NOTE THAT WE DO NOT SEND YOU ANY MAIL UNLESS YOU PROVIDE POSTAL MAIL-COMMUNICATION CONSENT.

Phone *

Email *

Date of Birth (MM/DD/YYYY) *

Gender *

Male
Female

For both male & female: What may we help you with? Treatment options below are safe for BOTH males and females and also appropriate for taking all at the same time *

BLOOD PRESSURE: sildenafil (Viagra) 100 mg & tadalafil (Cialis)5 mg or 10 mg tabs to normalize and stabilize blood pressure (for both highs and lows)
ATTENTION & FOCUS: Improve mental focus, clarity, concentration, and staying awake: Male & Female: Improving mood (Male & Female: Improving mental clarity and concentration without caffeine: modafinil 200 mg twice daily without food, phentermine 37.5 mg 1/2 tab twice daily without food; sildenafil (Viagra) 100 mg 1/2 tab once or twice daily; tadalafil (Cialis) 5 mg or 10 mg once daily
STRESS & ANXIETY: Improving mental clarity and concentration to focus on the big picture: modafinil 200 mg half tab twice daily without food, sildenafil (Viagra) 100 mg 1/2 tab once or twice daily; tadalafil (Cialis) 5 mg or 10 mg once daily
MOOD AND MENTAL HEALTH: Improving mental clarity and concentration without caffeine: modafinil 200 mg twice daily without food, phentermine 37.5 mg 1/2 tab twice daily without food; sildenafil (Viagra) 100 mg 1/2 tab once or twice daily; tadalafil (Cialis) 5 mg or 10 mg once daily
ELIMINATION OF CAFFEINE: Improving mental clarity and concentration without caffeine: modafinil 200 mg twice daily without food, phentermine 37.5 mg 1/2 tab twice daily without food; sildenafil (Viagra) 100 mg 1/2 tab once or twice daily; tadalafil (Cialis) 5 mg or 10 mg once daily
WEIGHT LOSS: modafinil 200 mg twice daily without food, phentermine 37.5 mg 1/2 tab twice daily without food; sildenafil (Viagra) 100 mg 1/2 tab once or twice daily; tadalafil (Cialis) 5 mg or 10 mg once daily
INSOMNIA: Vitamin B-12 & Lipotropic (Fat Burner) subcutaneous injection 4 hrs before bed every other day to promote more restful, and improve the overall quality sleep.

If you have other interest, please list: *

Did you experience any complications or side effects?

Do you remember what you were previously prescribed and how did the medications/injections worked for you? *

Females: When was your last menstrual period?

Females: Are you using contraception/preventing pregnancy?

Height *

Weight *

What's Your 3 Main Goals of Treatment? *

Do you know what worked for you and what you would like to be treated with? *

Current Blood Pressure *

Do you have a PCP/GYN? When was your last routine medical exam? *

Current Medications *

Drug Allergies *

Have you ever had any allergic or adverse reaction to vitmains or lidocaine? If yes, please explain. *

Past Surgeries *

Do you have heart disease or heart murmur? *

Do you have any history of passing out or syncope? *

Do you have a history of substance abuse? *

Do you have a high thyroid condition? (hyperthyroidism) *

Do you have glaucoma and/or Leber's Hereditary Optic Neuritis? *

Do you have any psychiatric or mental conditions? *

Do you have an eating disorder? *

Do you have a history of strokes? *

Do you have a seizure disorder? *

Do you have ADHD? *

Are you interested in Botox or Fillers?

Yes, Botox and/or Fillers
No

Please email hello@elevationweightloss.com for more information.

Consent to electronic communications: *

I give permission to my provider to contact me through text-messages, phone calls, and by email. I agree to the terms of use in consenting for electronic communications.
I'd prefer an in-office visit and will be booking by calling the office phone or http://www.elevationweightloss.setmore.com
------DO NOT TEXT or EMAIL ME--------

I have read and understand the consent form. I have agreed to submit this information by electronic means. I am electronically signing this form and verifying all information I have provided is true. Write "NO" for no consent. *

Sign Here.

Please type any additional comments or explain any yes questions here:

I have read and understand the statement of informed consent for the use of phentermine and acknowledge that I will have opportunities to ask questions during my telehealth visit. I am signing my FULL NAME below to allow consent for phentermine use. Write "NO" for no consent. *

Sign Here

I have read and understand the statement of informed consent for the use of HCG/sermorelin and acknowledge that I will have opportunities to ask questions during my telehealth visit. I am signing my FULL NAME below to allow consent for HCG/sermorelin use. Write "NO" for no consent. *

Sign Here

I have read and understand the statement of informed consent for the use of Vitamin B-12/Fat Burner Lipotropic/Vitamin-C injections and acknowledge that I will have opportunities to ask questions during my telehealth visit. I am signing my FULL NAME below to allow consent for B-12/Fat Burner Lipotropic/Vitamin-C injections use. Write "NO" for no consent. *

Sign Here. Write "NO" for no consent to B12/Fat Burner/Vitamin-C injections.

Consents are valid when you have decided to pursue the weight loss option. Payment is due at the time services are rendered. According to FDA Policy Sec. 460.300, I acknowledge that I cannot return or receive refunds for medications and/or injections once the medications/injections leave the office regardless of effectiveness or possible adverse reactions. All service fees paid are FINAL. *

I Agree
I Disagree

STATEMENT OF INFORMED CONSENT FOR USE OF PHENTERMINE: I have sought the medical services of Elevation Medical Weight Loss, Inc. (Elevation) due to my excess weight or obesity. I understand I will need to change my diet, exercise frequency and behaviors to aid in my long-term weight reduction efforts. and have discussed with Elevation the limited success I have had in losing weight by diet and exercise alone. I understand I will be prescribed phentermine, a drug which stimulates the nervous system and seems to act as an appetite suppressant. I understand that the management of my weight will require a lifelong effort, no matter what method of weight reduction I choose. I understand that no drug, by itself, can provide a quick fix for the problem of weight reduction and management. I understand that manufacturers and the FDA have made recommendations concerning the daily dosage and duration of use of phentermine. Although recommended daily dosage may vary somewhat between different brands of phentermine, the most common recommended daily dosages are 30 mg and 37.5 mg per day. I understand that phentermine is recommended as a short term treatment for a period of a “few weeks” which is commonly thought to mean up to twelve (12) weeks. I understand that physicians are not bound or limited by the recommendations of the manufacturers and the FDA and can prescribe phentermine using their best medical judgement based upon my physical condition and response to the drug, as well as personal experience and other information which may be available to the medical community, I understand that the use of phentermine in a manner differing from that recommended by the manufacturers and the FDA has not been studied systematically or comprehensively. The safety and effectiveness of using phentermine in a manner differing from that recommended by the manufacturers and the FDA is unknown. I understand that one who is overweight or obese has a heightened risk of suffering from high blood pressure, heart disease, diabetes, heart attack, stroke and arthritis (particularly involving the hips, knees and feet) Depression is more common in obese persons than in others. I understand that the risks of incurring these conditions tend to increase as one’s obesity increases. I understand that my use of phentermine may expose me to the risks of various conditions, including but not necessarily limited to heart palpitations, tachycardia (rapid heartbeat), elevated blood pressure, nervousness, overstimulation, restlessness, dizziness, insomnia (inability to sleep), euphoria (sense of well-being), dysphoria (sense of unhappiness or depression), tremor, headache, dry mouth, diarrhea, constipation, other gastrointestinal disturbance, medication allergies, impotence, or changes in libido (sex drive). I further understand that my use of phentermine may expose me to the less probable but more serious risk of sustaining primary pulmonary hypertension (PPH), a potentially life-threatening condition. I understand that some scientists and health care providers believe that the use of phentermine may increase the risk of heart disease, including damage to the heart valves, particularly when this drug is used in combination with other medications. As such, I understand that my use of phentermine, as with my use of any other drug may lead to serious injury or death. I understand the risks set forth above to my satisfaction. I have had an opportunity to ask questions I have concerning these and any other potential risks. I am encouraged to ask questions as concerns may arise. I should promptly bring any questions I have to the attention of a qualified physician. I have, to the best of my knowledge and ability, advised Elevation of my medical history and my family’s history of arteriosclerosis, cardiovascular disease, hypertension (high blood pressure, hyperthyroidism or any thyroid problems, use of drugs and other substances, diabetes, heart attack, heart disease, respiratory problems, pregnancy, glaucoma. I have also advised Elevation of my history regarding any psychiatric or mental disorders, prior use of any diet drugs, including over-the-counter products, treatment for any eating disorders, and treatment for substance abuse. I understand that if I begin to experience any unusual or unexpected symptoms at any time after I begin using phentermine, I should immediately contact my doctor. Unusual symptoms may include, but are not limited to, shortness of breath, edema (swelling of hands, legs or feet, heart palpitations or tachycardia (rapid heartbeat), nervousness, restlessness, insomnia, tremor, rapid breathing or respiration, or inability to tolerate exercise or activity. I understand that I may seek help from another qualified physician or go to a hospital emergency room. I understand that phentermine is a Category X medicine and can potentially cause fetal birth defects and/or miscarriages should I become pregnant. Therefore, I will not actively attempt to conceive while taking this medication. I understand that I should use a method of contraception, (either condoms, birth control, IUD, etc.) while taking this medication. Furthermore, I understand that should I become pregnant, I must discontinue the phentermine immediately and inform my doctor. I understand that I should use phentermine in the manner prescribed by the doctor and not provide this medication to any other person. I understand that I should not increase my dosage of phentermine or use it with any other drug or substance without the recommendation of my doctor . Serious injury or death can result from improper use of medications and/or the illegal transfer of medications to another individual. I understand that I may decline to begin treatment using phentermine. I also understand that I may stop using phentermine at any time in the future, but should notify my doctor before doing so. I recognize that it is safer to diet alone. I am requesting medication to help control my appetite. I assume responsibility for taking my diet pills and waive Elevation Medical Weight Loss of any liability. My health has been good and I will advise Elevation Medical Weight Loss should my health change. I have read and understand this consent form. I have had the opportunity to ask questions concerning this consent form and the medications to be prescribed for me. Any questions I have asked have been answered to my satisfaction. I understand that I should not sign this consent form unless I understand its contents, as well as the risks and benefits associated with the treatment proposed by Elevation Medical Weight Loss. I agree to release the physician and facility from any liability associated with HCG/Sermorelin treatment. In the event a dispute arises over the outcome of this treatment, I consent solely to arbitration as a legal means of settlement. Payment is due at the time services are rendered. According to FDA Policy Sec. 460.300, I acknowledge that I cannot return or receive refunds for medications and/or injections once the medications/injections leave the office regardless of effectiveness or possible adverse reactions. All service fees paid are FINAL. Write "NO" for no consent. *

Sign Here. Write "NO" for no consent.

STATEMENT OF INFORMED CONSENT FOR USE OF HCG AND/OR SERMORELIN: I have sought the medical services of Elevation Medical Weight Loss due to my excess weight or obesity. I have discussed the limited success I have had in losing weight by diet and exercise alone. I understand I will be prescribed medications. These medications may include Human Chorionic Gonadotropin (an appetite suppressant) or Sermorelin (a medication that promotes the secretion of human growth hormone). I understand I will need to change my diet , exercise frequency and behaviors to aid in my long-term weight reduction efforts. I understand that the management of my weight will require a lifelong effort, no matter what method of weight reduction I choose. I understand that no drug can provide a quick fix for the problem of weight reduction and management. I understand that the use of HCG and/or sermorelin in a manner differing from that recommended by the manufacturers and approved by the FDA has not been studied systematically or comprehensively. The safety and effectiveness of using HCG and/or sermorelin in a manner differing from that recommended by the manufacturers and the FDA is unknown. I understand that one who is overweight or obese has a heightened risk of suffering from high blood pressure, heart disease, diabetes, heart attack, stroke and arthritis (particularly involving the hips, knees and feet) Depression is more common in obese persons than in others. I understand that the risks of incurring these conditions tend to increase as one’s obesity increases. Prior to my treatment, I have fully disclosed any medical conditions or diseases such as pregnancy, trying to get pregnant, breastfeeding, history of gallbladder disease, diabetes, autoimmune diseases, HIV, heart disease, liver disease, kidney disease, uncontrolled high blood pressure, seizure disorders, blood disorders, anemia, thalassemia, hemophilia, etc), emphysema or asthma, and any history of stroke or cancer. These contraindications have been fully discussed with me. If I fail to disclose any medical condition that I have, I release the physician and facility from any liability associated with this treatment. I recognize that it is safer to diet alone . I am requesting medications to assist me in my weight loss goals. I assume responsibility for taking my medications and waive Elevation Medical Weight Loss of any liability. My health has been good. I will advise Elevation Medical Weight Loss should my health change. I understand HCG and/or Sermorelin are not FDA approved for weight loss and this application may be considered as “off-label use”. I understand there is no medical evidence to support the use of HCG and/or Sermorelin for this purpose. I further understand that HCG and/or Sermorelin have not been approved by the FDA as safe and effective in the treatment of obesity or weight control. There is no substantial evidence that HCG and/or Sermorelin increases weight loss beyond that resulting from caloric restriction, that it causes a more attractive or “normal” distribution of fat, or that it decreases the hunger and discomfort associated with calorie-restrictive diets. HCG treatment is generally free of negative side effects, but it carries with it the following risks: Ovarian Hyperstimulation Syndrome, arterial thromboembolism, blood clots, risk of multiple pregnancies (twins, etc.), abnormal enlargement of breasts in men (gynecomastia), overstimulation of the ovaries causing production of many ova (eggs( in women, acne, tiredness, changes in mood, local injection site reactions (such as swelling, itchiness, etc.), excessive fluid retention in the body (edema), hair loss, prostate hypertrophy, difficulty breathing, and death. Although remote, I understand HCG treatment may involve these risks and other unknown risks. Symptoms of Ovarian Hyperstimulation Syndrome include severe pelvic pain, swelling of the hands or legs, stomach pain/swelling, shortness of breath, weight gain, diarrhea, nausea/vomiting, or urinating less than normal. I agree to notify Elevation Medical Weight Loss if I experience any of these rare adverse symptoms. I understand that HCG is absolutely contraindicated during pregnancy and breastfeeding. I understand that it is my responsibility to inform the medical staff if I am pregnant, if I am trying to get pregnant, or if I become pregnant during the course of therapy. I understand that HCG is used for infertility treatments and I have an increased chance of pregnancy while on HCG. Multiple birth control methods should be used during HCG therapy. However, HCG is contraindicated for women using hormonal IUD for birth control. Therefore, I agree to use condoms and/or abstinence as birth control methods for the duration of HCG therapy. I understand if HCG therapy is used in young boys, it may cause early puberty. I agree to alert Elevation to any of the following symptoms of early puberty: deepen voice, pubic hair growth, increase acne, and increased sweating. I understand that Sermorelin may cause pain and swelling at the injection site. I understand that, rarely, Sermorelin may cause flushing, dizziness, headache, sleepiness, nausea, vomiting, or hyperactivity. I agree to notify Elevation immediately if the following rare side effects occur: trouble swallowing, chest tightening, or vomiting. I further understand that allergies to Sermorelin are very unlikely, but can include rash, swelling, trouble breathing, and dizziness. I understand that I may stop this program at any time. While adverse side effects or complications are not expected, in the event an illness does occur, I understand that I need to contact Elevation Medical Weight Loss, inc. immediately. If I experience an emergency situation, I understand that I need to go to the emergency room. I understand the risks set forth above to my satisfaction. I have had an opportunity to ask questions I have concerning these and any other potential risks. I am encouraged to ask questions as concerns may arise. I should promptly bring any questions I have to the attention of a qualified physician. NOTE: if HCG is used correctly, there is little concern for side effects for both men & women. HCG is a natural water-based hormone present in both men and women (although it is produced in great amounts in pregnant females). Side effects reported are for women using HCG for fertility treatments. When HCG is used to promote weight loss, a much smaller dosage is used compared to that for fertility treatments (150 IU for weight loss vs 10,000 IU for fertility purposes). Accordingly, there are rarely side effects reported while using HCG therapy for weight loss. I have read and understand this consent form. I have had the opportunity to ask questions concerning this consent form and the medications to be prescribed for me. Any questions I have asked have been answered to my satisfaction. I understand that I should not sign this consent form unless I understand its contents, as well as the risks and benefits associated with the treatment proposed by Elevation Medical Weight Loss. I agree to release the physician and facility from any liability associated with HCG/Sermorelin treatment. In the event a dispute arises over the outcome of this treatment, I consent solely to arbitration as a legal means of settlement. Payment is due at the time services are rendered. According to FDA Policy Sec. 460.300, I acknowledge that I cannot return or receive refunds for medications and/or injections once the medications/injections leave the office regardless of effectiveness or possible adverse reactions. All service fees paid are FINAL. Write "NO" for no consent. *

Sign Here

Vitamin B-12 Injection Consent Form: I am requesting a B-vitamin/amino acid injection in the muscle. This injection may also contain any of the Vitamin B, Methionine, Inositol, Choline, L-Carnitine, or other amino acids. I understand that I am receiving a nutrient/vitamin injection. Most side effects are mild or moderate in nature, and their duration is short lasting (several hours, but very rarely up to 5 days). The most common side effects include, but are not limited to, temporary injection site reactions like: pain/tenderness, firmness, redness, swelling, bruising, swelling, lumps/bumps, itching, discoloration, and tingling. As with all injections, there are risks such as infection, scarring, skin atrophy, and neuropathy. I agree to release Elevation Medical Weight Loss and the medical practitioner from any liability arising from injection therapy. Payment is due at the time services are rendered. According to FDA Policy Sec. 460.300, I acknowledge that I cannot return or receive refunds for medications and/or injections once the medications/injections leave the office regardless of effectiveness or possible adverse reactions. All service fees paid are FINAL. Write "NO" for no consent. *

Sign Here. Write "NO" for no consent.

CONSENT TO OPT-IN to EMAIL/TEXT/VIDEO COMMUNICATION: I acknowledge that the transmission of my personal information by email, phone, texting and/or video conferencing has a number of risks. These include, but are not limited to, the following risks: Emails, phone calls/voicemails, and text messages can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients. Email and text senders can easily misaddress an email or text and send the information to an undesired recipient. Backup copies of emails and texts may exist even after the sender and/or the recipient has deleted his or her copy. Employers and on-line services have a right to inspect emails sent through their company systems. Emails, phone calls, voicemails, and texts can be intercepted, altered, forwarded or used without authorization or detection. Emails, voicemails, and texts can be used as evidence in court. Emails, phone calls, voicemails, and texts may not be secure and therefore it is possible that the confidentiality of such communications may be breached by a third party Conditions for the use of email and texts: The provider cannot guarantee but will use reasonable means to maintain the security and confidentiality of email, phone, voicemail, and text information sent and received. The provider is not liable for improper disclosure of confidential information that is not caused by the provider’s intentional misconduct. Clients/Parent’s/Legal Guardians must acknowledge and consent to the following conditions: The provider cannot guarantee that any particular email and/or text will be read and responded to within any particular period of time. The provider will respond to text messages, voicemails, and emails Monday-Thursday during the hours of 9AM-5PM, unless otherwise specified. Voicemails, text messages, and emails will not be answered outside of these hours or on the weekends/holidays. Email and texting is not appropriate for urgent or emergency situations. If you experience a mental health emergency, please go to your nearest emergency room and/or call 911. Email and texts should be concise. The client/parent/legal guardian should call and/or schedule an appointment to discuss complex and/or sensitive situations. Email communication will usually be printed and filed into the client’s medical record. Texts may be printed and filed as well. Clients/parents/legal guardians should not use email or texts for communication of sensitive medical information. The provider is not liable for breaches of confidentiality caused by the client or any third party. It is the client’s/parent’s/legal guardian’s responsibility to follow up and/or schedule an appointment if warranted. Non-face-to-face evaluation and management of services provided by the provider to a client via telephone is subject to billing if initiated by an established client, or guardian of an established client. Client Acknowledgement and Agreement I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communication of cell phones, email and/or texts between my provider and me, and consent to the conditions and instructions outlined, as well as any other instructions that my provider may impose to communicate with me by email or text. By signing this form, I authorize the provider to send text messages to my cell phone regarding scheduling and treatment. I understand that standard text messaging rates will apply to any messages received. I also understand that I or the provider may revoke this permission in writing at any time. I agree not to hold the provider liable for any electronic messaging. The practitioner will take reasonable steps to ensure that all information shared through email is kept private and confidential. However, Elevation Medical Weight Loss, is not liable for improper disclosure of confidential information that is not a result of our negligence or misconduct. Patient information is protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320 et seq. 45 C.F.R. Parts 160 & 164, and the Confidentiality Law, 42 U.S.C. 290dd-2, 42 C.F.R. Part 2 Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate any alcohol or drug abuse. INFORMED CONSENT If you consent to the use of email/text messaging, you are responsible for informing your practitioner of any type of information that you do not want sent to you by email/text message other than the information detailed in Section B. You are responsible for protecting your password and access to your email account/ mobile phone and any email/text message you send or you receive from Elevation Medical Weight Loss to ensure your confidentiality. Your practitioner cannot be held liable if there is a breach of confidentiality caused by a breach in your account security. Any email/text message that you send that discussed your diagnosis or treatment constitutes informed consent to the information being transmitted. If you wish to discontinue email/text correspondence, you must submit written consent informing your practitioner that you are withdrawing consent to email/text correspondence. Write "NO" for no consent. *

Sign Here. Write "NO" for no consent.

Upload Valid PHOTO ID Here

Click or drag a file to this area to upload.

If you cannot do this you may email your valid PHOTO ID to: hello@elevationweightloss.com

Are you interested in Botox or Dermal Fillers? if yes, please email drcooper@elevationweightloss.com or call us 412-458-5042 to book a consult

if yes, please email drcooper@elevationweightloss.com or call us 412-458-5042 to book a consult

By checking this box, I acknowledge that my consult may take 48 business hrs to process and our provider may not be able to schedule me for a consult until 14 business days after I submit my New Patient Form. I understand and accept. *

By checking this box, I acknowledge that my consult may take 48 business hrs to process and our provider may not be able to schedule me for a consult until 14 business days after I submit my New Patient Form. I understand and accept.
By checking this box, I acknowledge that my consult may take 48 business hrs to process and our provider may not be able to schedule me for a consult until 14 business days after I submit my New Patient Form. I understand and accept.

Are you interested in getting started with Testosterone Replacement Therapy (TRT) through the use of injections, oral agents, and supplementary oral medications, including but not limited to: Sildenafil (Viagra) and tadalafil (Cialis) are used in both men and women. These two blood pressure agents are known as anti-hypertensive medications, help improve blood circulation, increase airflow and overall breathing through targeting specific receptors in the heart and lungs. These medications are used to prolong lifespan, improve long-term happiness, treat depression, and allow patients to feel better. DO NOT TAKE sildenafil (Viagra) and tadalafil (Cialis) if you are currently taking any nitrates medications. However, sildenafil (Viagra) and tadalafil (Cialis) are safe to use during pregnancy and/or breastfeeding. *

Yes, please charge my card $70 for 10 tabs of sildanafil (VIAGRA) 100 mg (20 doses total) and send the services to my address if I qualify for this treatment
Yes, please charge my card $90 for 30 tabs of tadalafil (CIALIS) 5 mg (30 doses total; take 1 tab daily by mouth every morning with or without food) and send the services to my address if I qualify for this treatment
Yes, please charge my card $150 for 15 tabs of tadalafil (CIALIS) 10 mg (30 doses total; take 1/2 (half) tab daily by mouth every morning with or without food) and send the services to my address if I qualify for this treatment
OTHER: Yes, please charge my card $100 for 30 tabs of modafinil (PROVIGIL) 200 mg (30 doses total; take 1/2 (half) to 1 (one) tab daily by mouth every morning WITHOUT FOOD and send the services to my address if I qualify for this treatment
OTHER: Yes, please charge my card $150 for 8 sets of Vitamin B-12 1000mcg & Lipotropic 1 mL subcutaneous injections with 8 alcohol prep pads to be self-adminstered 4 hrs before bed every other night for insomnia and to improve quality of sleep. Send the services to my address if I qualify for this treatment

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Payment Authorization Form: I understand that my credit card/payment number on this form will be destroyed after payment is processed and that no payment information is stored. Elevation Medical will reach out to me either by email or text messages at the email or number I submitted to schedule a telephone health consult. I agree to allow for 72 business hours to fulfill my mail order requests and my order should be delivered within 7-10 business days. I acknowledge that I will receive a confirmation of payment and USPS tracking number by email at the email address I provided. I understand that there may be potential delays in receiving mail, and the delay may be up to 2 weeks. I understand that if I opt for the package to be sent without a signature required for drop-off, I accept all responsibility and liability, and may not hold Elevation Medical Weight Loss liable for lost or damaged packages. *

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