Weight Loss Visit

Current Location*
Location Requirement Notice
In accordance with telemedicine regulations, you must be physically located in a state where our providers are licensed at the time you complete and submit this visit form.

Residency in a licensed state is not required. Patients may complete visits while temporarily present in a licensed state (e.g., travel or vacation). When clinically appropriate, prescriptions may be sent to a pharmacy in your home state.

If you are not currently physically located in a licensed state, you are not eligible to proceed at this time. Please complete this visit once you are physically present in a licensed state.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
What is your birth-assigned gender?*
Phone Number*
Please enter a valid phone number.
Email*

Confirmation Emailexample@example.com
Address*
Legal Guardian's Name*

First NameLast Name
I attest that I am the legal guardian and consent to treatment of the minor listed above. *

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Terms of Service
I am not covered by Medicare or MedicaidI am covered by Medicare or Medicaid and I agree to the terms of the Advanced Beneficiary Notice (ABN)
Advance Beneficiary Notice

Patient is solely responsible for paying out-of-pocket the full charge for this visit. This service is not covered under Medicare or Medicaid. Omnia TeleHEALTH will not submit a bill to or request for payment from Medicare and Medicaid or any other payor.

You should not use Omnia TeleHEALTH if you are experiencing an emergency. Emergencies include but are not limited to:
- Severe of unusual chest pain
- Severe shortness of breath
- Symptoms of a stroke (such as facial drooping, arm weakness, or speech difficulties)
- Thoughts of harming yourself or others
Are you experiencing an emergency? If you are experiencing an emergency, call 911 or go to an emergency room immediately.*

Yes, I am having an emergencyNo, I am not having an emergency

Pharmacy Information
Pharmacy Name*
Pharmacy's Address*
Shipping Information

Please enter and verify the address where you would like your medication shipped to.
Shipping Address*

If Omnia's providers determine that weight loss medications are not appropriate, you will not be charged for the visit (or you will be refunded).

Once the visit is reviewed and completed, there will be no refunds for the visit.

Weight Loss Telemedicine Visit

$69.00

Enter coupon

Total

$0.00

Terms of Service