RETURNING PATIENT TELEHEALTH REQUEST

(This is only available for established patients who live in WV or PA)

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 (We CANNOT ship to Ohio)

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

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

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. *

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**

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 (We CANNOT ship to Ohio). We are not responsible for damaged or undelivered mail by the USPS or patient's typographical errors. *

We are not responsible for damaged or undelivered mail by the USPS or patient's typographical errors. Please Initial to confirm.

Additional Notes/Comments

Name

Locations