Returning Patient Refill Request Order Form (10/16/2020) Please enable JavaScript in your browser to complete this form.Name *FirstLastDate of Birth (MM/DD/YY) *Patient's Last Blood PressurePatient's Current WeightPatient's Desired Mailing Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *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 necessaryWhich is your regular clinic location? *Greentree/Crafton - 2350 Noblestown Rd. Ste 110 Pittsburgh, PA 15205 North Hills - 1130 Perry Hwy. Ste 9 Pittsburgh, PA 15237South Hills - 5301 Grove Rd. Suite 617A Pittsburgh, PA 15236Monroeville - 3747 William Penn Hwy, Monroeville, PA 15146Weirton - 241 Three Springs Dr. Ste 12 Weirton, WV 26062Morgantown - 5004 Mid Atlantic Dr. Morgantown, WV 26508I 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. *YesNoIf 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) - $ 90.00RETURNING TELEHEALTH REQUEST for 1 month Lannett PINK($90) - $ 90.00RETURNING TELEHEALTH REQUEST for 2 months KVK ($170) - $ 170.00RETURNING TELEHEALTH REQUEST for 2 months Lannett ($170) - $ 170.00RETURNING TELEHEALTH REQUEST for 2 months- 1 KVK and 1 Lannett ($170) - $ 170.00RETURNING TELEHEALTH REQUEST for EVERYTHING PLAN $335 KVK (yellow) - please review instructions on how to mix HCG - $ 335.00RETURNING TELEHEALTH REQUEST for EVERYTHING PLAN $335 (PINK Lannett) - please review instructions on how to mix HCG - $ 335.00HCG/Sermorelin & mixing solutionsRETURNING TELEHEALTH REQUEST for 1 HCG inj vial + supplies → $195 RETURNING TELEHEALTH REQUEST for 2 HCG inj vials + supplies → $390RETURNING TELEHEALTH REQUEST for 1 month sermorelin inj + supplies→ $235 RETURNING TELEHEALTH REQUEST for 2 months sermorelin inj + supplies→ $470RETURNING 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 → $145B-12 + LipoPlus Injection PackagesRETURNING TELEHEALTH REQUEST for 1 month - 4 B12 + 4 LipoPlus → $75 - $ 75.00RETURNING TELEHEALTH REQUEST for 2 months - 8 B12 + 8 LipoPlus → $145 - $ 145.00RETURNING TELEHEALTH REQUEST for 4 months - 16 B12 + 16 LipoPlus → $245 - $ 245.00B-12 Vitamins Injection PackagesRETURNING TELEHEALTH REQUEST for 1 month - 4 B12 1000mg/ml in 1ml inj → $30RETURNING TELEHEALTH REQUEST for 2 months - 8 B12 1000mg/ml in 1ml inj → $55RETURNING TELEHEALTH REQUEST for 4 months - 16 B12 1000mg/ml in 1ml inj → $100LipoPlus Fat Burner (BioBoost) Injection PackagesRETURNING TELEHEALTH REQUEST for 1 month - 4 LipoPlus 1ml inj → $50RETURNING TELEHEALTH REQUEST for 2 months- 8 LipoPlus 1ml inj → $95RETURNING TELEHEALTH REQUEST for 4 months - 16 LipoPlus 1ml inj → $180Super B-complex Injection Packages (requires ice pack) RETURNING TELEHEALTH REQUEST for 1 month - 4 Super-B complex + B-12→ $75 - $ 75.00RETURNING TELEHEALTH REQUEST for 2 months - 8 Super-B complex + B-12 → $145 - $ 145.00RETURNING TELEHEALTH REQUEST for 4 months - 16 Super-B complex + B-12 → $245 - $ 245.00SHIPPING 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 LicensePaying with Debit/Credit CardFirstLastBilling AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCredit Card NumberCredit Card Expiration DateCredit Card CVVI 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 herePayment 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. *Clear SignatureSign 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. 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. PhoneSubmit