Returning Patient Refill Request Order Form (10/16/2020)

Name *

First

Last

Date of Birth (MM/DD/YY) *

Patient's Last Blood Pressure

Patient's Current Weight

Patient's Desired Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Preferred method of contact: *

Call Me in the next 72 business hrs (please confirm correct phone above)
E-mail Me in the next 72 business hrs (please confirm correct email above)
Do not contact me unless absolutely necessary

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. *

If no, please explain here:

MEDICAL WEIGHT LOSS RETURNING TELEHEALTH APPT REQUEST: (KVK is yellow/amber; Lannett is pink/magenta)

RETURNING TELEHEALTH REQUEST for 1 month KVK YELLOW ($90) - $ 90.00
RETURNING TELEHEALTH REQUEST for 1 month Lannett PINK($90) - $ 90.00
RETURNING TELEHEALTH REQUEST for 2 months KVK ($170) - $ 170.00
RETURNING TELEHEALTH REQUEST for 2 months Lannett ($170) - $ 170.00
RETURNING TELEHEALTH REQUEST for 2 months- 1 KVK and 1 Lannett ($170) - $ 170.00
RETURNING TELEHEALTH REQUEST for EVERYTHING PLAN $335 KVK (yellow) - please review instructions on how to mix HCG - $ 335.00
RETURNING TELEHEALTH REQUEST for EVERYTHING PLAN $335 (PINK Lannett) - please review instructions on how to mix HCG - $ 335.00

HCG/Sermorelin & mixing solutions

RETURNING TELEHEALTH REQUEST for 1 HCG inj vial + supplies → $195
RETURNING TELEHEALTH REQUEST for 2 HCG inj vials + supplies → $390
RETURNING TELEHEALTH REQUEST for 1 month sermorelin inj + supplies→ $235
RETURNING TELEHEALTH REQUEST for 2 months sermorelin inj + supplies→ $470
RETURNING TELEHEALTH REQUEST for B12 + Lipo (5.3ml) to mix 1 HCG → $75
RETURNING TELEHEALTH REQUEST for B12 + Lipo (5.3ml x 2) for 2 HCG → $145

B-12 + LipoPlus Injection Packages

RETURNING TELEHEALTH REQUEST for 1 month - 4 B12 + 4 LipoPlus → $75 - $ 75.00
RETURNING TELEHEALTH REQUEST for 2 months - 8 B12 + 8 LipoPlus → $145 - $ 145.00
RETURNING TELEHEALTH REQUEST for 4 months - 16 B12 + 16 LipoPlus → $245 - $ 245.00

B-12 Vitamins Injection Packages

RETURNING TELEHEALTH REQUEST for 1 month - 4 B12 1000mg/ml in 1ml inj → $30
RETURNING TELEHEALTH REQUEST for 2 months - 8 B12 1000mg/ml in 1ml inj → $55
RETURNING TELEHEALTH REQUEST for 4 months - 16 B12 1000mg/ml in 1ml inj → $100

LipoPlus Fat Burner (BioBoost) Injection Packages

RETURNING TELEHEALTH REQUEST for 1 month - 4 LipoPlus 1ml inj → $50
RETURNING TELEHEALTH REQUEST for 2 months- 8 LipoPlus 1ml inj → $95
RETURNING TELEHEALTH REQUEST for 4 months - 16 LipoPlus 1ml inj → $180

Super B-complex Injection Packages (requires ice pack)

RETURNING TELEHEALTH REQUEST for 1 month - 4 Super-B complex + B-12→ $75 - $ 75.00
RETURNING TELEHEALTH REQUEST for 2 months - 8 Super-B complex + B-12 → $145 - $ 145.00
RETURNING TELEHEALTH REQUEST for 4 months - 16 Super-B complex + B-12 → $245 - $ 245.00

SHIPPING CHOICE (REQUIRED): *

Flat rate 7-10 business days (processing time up to 72 business hrs)

CARECREDIT Number (if applicable)

If paying with CareCredit, please provide CareCredit Card Number, Name of Card Holder, and expiration date of your Driver License

Paying with Debit/Credit Card

First

Last

Billing Address

Address Line 1

Address Line 2

City

State

Zip Code

Credit Card Number

Credit Card Expiration Date

Credit Card CVV

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

I hereby authorize you to store my card and a charge of $200 or less in my provided credit card below for medical services rendered. I will receive a copy of my receipt either via snail-mail USPS or by email.
I hereby authorize you to store my card and a charge of $500 or less in my provided credit card below for medical services rendered. I will receive a copy of my receipt either via snail-mail USPS or by email.
I hereby authorize you to store my card and a charge of $1200 or less in my provided credit card below for medical services rendered. I will receive a copy of my receipt either via snail-mail USPS or by email.
No, please don't charge me. I will render payments during my in-office physical visit instead.

Please contact us if you have questions. We only charge fees for the services provided and ONLY if you agree to the charges.

Please confirm Patient's Desired Mailing Address *

Your Notes/Comments *

Enter your notes/comments here

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. *

Sign Here

I AM REQUESTING that you call me on my cell phone number DURING which time and date (write below) _______________. I AGREE THAT THERE IS A POTENTIAL DELAY OF 72 BUSINESS HOURS TO FOR A CALL-BACK. However, we typically send out plans and your instructions in the mail the same business day we speak to you on the phone. I agree to wait 3 business days for a phone call from Elevation Medical, then I will be provided with a tracking number of the mailed-out dietary guidance.

Name