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 (This is only available for established patients that live in WV or PA.) 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 Address (We CANNOT ship to Ohio)Address 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 (We CANNOT ship to Ohio) *Additional Notes/CommentsNameSubmit
