Virtual Appointment

Health-X

520 W Erie St, Chicago, IL 60654

support@health-x.com

(888) 488-1977

Patient's Full Name*

First NameLast Name

Date of Birth *

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

E-mail Address*

example@example.com

Reason for Visit

For a weight loss consultation select "Weight Loss Program"

Coverage only in Illinois, Florida, Indiana, & Wisconsin.

Height (ft.)*

Height (in.)*

Weight*

Gender Identity*

Race

Marital Status

Upload your government issued ID.

Terms:*

The cost of this consultation is $150.00. Prescription medication requires a consultation with one of our board-certified physicians.

My Products

Consultation

$150 one-time payment

Total

$0.00

Card Information

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

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Information about your medical history:*

	Yes	No
Allergies (If yes, please list allergens and reactions.)
Medications (If yes, please list medications and dosages.)
Chronic Medical Conditions (If yes, please list conditions.)
Previous Surgeries: (If yes, please list surgeries and dates.)

Allergies

Medications

Chronic Medical Conditions

Previous Surgeries

Please describe the main reason for your visit and any symptoms you are experiencing.

Appointment*

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Coverage only in Illinois, Florida, Indiana, & Wisconsin.

Vital Statistics

Identification

Payment

Medical History

Appointment

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