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.

Height (ft.)*

Height (in.)*

Weight*

Gender Identity*

Race

Marital Status

Upload your insurance card or enter your details below.

Insurance Provider

Insurance Membership ID #

Group ID #

Enter your insurance group ID #, if you have one.

File Upload

Secondary Insurance Provider

Secondary Insurance Membership ID #

Secondary Group ID #

Enter your secondary insurance group ID #, if you have one.

Upload your government issued ID.

Terms:*

Your credit card will be authorized for $0.01. If you have insurance, the final amount will be adjusted according to your copay. If you do not have insurance the cost of this consultation will be 75.00$ and it will be processed during your appointment.

My Products

Consultation

$0 one-time payment

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.

Additional Information

Is there anything else you would like to let your healthcare provider to know?

Appointment*

By signing below, I acknowledge that the information provided is accurate to the best of my knowledge. I understand that this information will be used for my medical assessment and treatment. I authorize the immediate care medical team to provide necessary medical treatment and procedures.

I agree:*

HIPAA Notice of Privacy Practices & General Informed Medical Consent

Please verify that you are human*

Coverage only in Illinois.

Vital Statistics

Insurance

Secondary Insurance

Identification

Payment

Medical History

Appointment

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