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Telehealth
Services
Forms & Info
Contact
About
- About Dr. Cooper
- Coach Drew
Blog
- Testimonials
- Recipes

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Home / Telehealth Medical Weight Loss Consultations – Links here

Telehealth Medical Weight Loss Consultations – Links here

Please make an in-person appointment for your visit for a better experience and more success in your weight loss journey. **

Returning Patient Telehealth Appointment REQUESTS

1 MONTH STANDARD OR ENHANCED

PAY INVOICE for $98.01 HERE for 1 month of orange or PINK dietary packet (STANDARD)
PAY INVOICE $175.01 HERE for 1 month of ORANGE or PINK dietary packet with B-12 and Lipotropic Fat Burner (ENHANCED)

2 MONTHS STANDARD OR ENHANCED

PAY INVOICE $178.02 HERE for 2 months of orange, PINK, or mix and match dietary packet (STANDARD)
PAY INVOICE $329.02 HERE for 2 months of Orange, PINK, or MIX & MATCH dietary packet (ENHANCED)

B-12 / Lipotropic Fat Burner add-on

Pay invoice $40 for B-12 (in 8 weeks plan increments)
Pay invoice $85 B-12 + Lipotropic Fat Burner (4 weeks plan increments)

Options including HCG

PAY invoice $275 HERE for HCG with B-12 vitamins + Fat Burner (Lipotropic) Vitamins? $275
PAY invoice $210 HERE for HCG only with water 1-month plan
PAY INVOICE $343.01 HERE for 1 month of ORANGE or PINK dietary packet including HCG with B-12 vitamins + Fat Burner (Lipotropic) Vitamins (EVERYTHING RAPID)
PAY INVOICE $339 for 2 months of orange, PINK, or mix and match dietary packet including HCG with B-12 vitamins + Fat Burner (Lipotropic) Vitamins (EVERYTHING RAPID), select Qty 2 before checking out

Sermorelin

PAY an invoice $243 HERE for sermorelin with medical water 1-month plan

TELEHEALTH & LOCAL PHARMACY Refill Service Request

Name *

First

Last

Date of Birth (MM/DD/YY) *

Returning Patient Telehealth Request: *

I know exactly what I need for refills
I have an idea of what I need for refills on and need a provider to contact me for recommendations
I do not know what I am interested in and need a provider to contact me via phone or email for recommendations

Patient's Last Blood Pressure *

Patient's Height *

Patient's Current Weight *

Any adverse side effects on your current treatment plan?

Patient's Desired Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

We will need to call you to discuss your telehealth at your provided phone number *

Call Me in the next 2-5 business days (please confirm correct phone above)

The phone number we call you may be from a blocked phone number or from our office phone

Which is your regular clinic location? *

Greentree/Crafton - 2350 Noblestown Rd. Ste 110 Pittsburgh, PA 15205
North Hills - 1130 Perry Hwy. Ste 9 Pittsburgh, PA 15237
South Hills - 5301 Grove Rd. Suite 617A Pittsburgh, PA 15236
Monroeville - 3747 William Penn Hwy, Monroeville, PA 15146
Weirton - 241 Three Springs Dr. Ste 12 Weirton, WV 26062
Morgantown - 5004 Mid Atlantic Dr. Morgantown, WV 26508

I am a current patient and I affirm that there have been no changes to my medication list, medical history/known medical conditions, and or surgeries. *

Yes
No

If no, please explain here:

Please let us know what you are requesting with your telehealth appt and what you may be interested in? *

Your Notes/Comments *

Enter your notes/comments here

I authorize consent for you to charge my credit card with my authorization to be charged a mutually-agreed upon service fees. **NOTE THAT ELEVATION MEDICAL SHALL NOT CHARGE YOUR CARD WITHOUT YOUR PERMISSION**

up to $100
up to $250
Up to $400
Up to $900
none

Name *

First

Last

Card Number

Card Expiration

Card CVV

(optional) Secured storage of credit card information confirmation signature: I authorize consent for Elevation Medical to securely store my credit card information for future requests for mutally-agreed upon service fees.

This is an optional field. Please sign here if you wish to have your credit card information securely stored.

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 unless I provided explicit authorization to securely store information above. 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. *

After signing your name, you may also write STORE or DO NOT STORE to confirm your choices in the signature box above.

Please confirm Patient's Desired Mailing Address *

Additional Notes/Comments

Phone

Locations

Elevation Medical Weight Loss Green Tree Pittsburgh (412) 458-5042
North Hills Pittsburgh (412) 847-8083
South Hills Pittsburgh (412) 819-4614
Monroeville (412) 6462134
Weirton WV (304) 914-3112
Morgantown WV (304) 777-2640
⇒ CONTACT US HERE FOR QUESTIONS/CONCERNS ⇐

© Elevation Medical Weight Loss 2021