New Patient Information Form

For in-person appt, you may book online via http://www.elevationweightloss.setmore.com
I understand that if I have my prescription sent to and filled at my local pharmacy, I am responsible both for Elevation Medical's service fee AND an additional pharmacy service fee. I may also be required to pay an additional $20-50 at the pharmacy depending on my pharmacy of choice and their policies and prices. I wish to receive my medication refills at my local pharmacy as a matter of convenience in spite of these additional fees/costs.
I understand that if I have my prescription sent to and filled at my local pharmacy, I am responsible both for Elevation Medical's service fee AND an additional pharmacy service fee. I may also be required to pay an additional $30-50 at the pharmacy depending on my pharmacy of choice and their policies and prices. I wish to receive my medication refills at my local pharmacy as a matter of convenience in spite of these additional fees/costs.
I understand that if I have my prescription sent to and filled at my local pharmacy, I am responsible both for Elevation Medical's service fee AND an additional pharmacy service fee. I may also be required to pay an additional $30-50 at the pharmacy depending on my pharmacy of choice and their policies and prices. I wish to receive my medication refills at my local pharmacy as a matter of convenience in spite of these additional fees/costs.
PLEASE NOTE THAT WE DO NOT SEND YOU ANY MAIL UNLESS YOU PROVIDE POSTAL MAIL-COMMUNICATION CONSENT.
Please email hello@elevationweightloss.com for more information.
Sign Here.
Sign Here
Sign Here
Sign Here. Write "NO" for no consent to B12/Fat Burner/Vitamin-C injections.
Sign Here. Write "NO" for no consent.
Sign Here
Sign Here. Write "NO" for no consent.
Sign Here. Write "NO" for no consent.
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
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.
You type here. Type "no" if you do not have any comments.