Telehealth **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 Please enable JavaScript in your browser to complete this form.Name *FirstLastDate of Birth (MM/DD/YY) *Returning Patient Telehealth Request: *I know exactly what I need for refillsI have an idea of what I need for refills on and need a provider to contact me for recommendationsI do not know what I am interested in and need a provider to contact me via phone or email for recommendationsPatient's Last Blood Pressure *Patient's Height *Patient's Current Weight *Any adverse side effects on your current treatment plan?Patient's Desired Mailing AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *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 phoneWhich 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: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 hereI 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 $100up to $250Up to $400Up to $900noneName *FirstLastCard NumberCard ExpirationCard 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.Clear SignatureThis 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. *Clear SignatureAfter 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/CommentsCommentSubmit
