Text2MD Telemedicine Consultation Request Form

1
Are you a New Patient?* This field is required.
Yes
No, I'm a returning patient
2
Select your state* This field is required.
Alabama
California
Florida
Georgia
Iowa
Idaho
Illinois
Maryland
New Jersey
New York
South Carolina
South Dakota
Utah
Virginia
3
Full Name* This field is required.
First Name
Last Name
4
Date of Birth* This field is required.
5
Date of Birth* This field is required.
Date
Month
Day
Year
6
Cell Phone Number* This field is required.
Please enter a valid phone number.
7
Email Address* This field is required.
example@example.com
8
How did you heard about our services?
Google search
Social Media (Facebook, Instagram, X, Youtube)
Word of Mouth
AI
Other
9
Telemedicine Informed Consent, HIPAA NOTICE OF PRIVACY PRACTICES And Refund Notice* This field is required.
10
Signature* This field is required.I have read and agree with Text2MD Telemedicine Informed Consent, HIPAA NOTICE OF PRIVACY PRACTICES And Refund Notice
Clear
11
Which service do you need?* This field is required.
Metabolic Health/Weight Loss & GLP-1 — pricing per plan selected (Starting at $142/month)
Long COVID Recovery - $250 Initial Consultation, $125 Follow Up Consultation
Hormone Therapy (HRT) - $250 Initial Consultation, $125 Follow Up Consultation
Gut Health & Metabolic Reset - $250 Initial Consultation, $125 Follow Up Consultation
Virtual DPC - Primary Care (Text2MD Annual Membership Only) $350/Year - Unlimited Text Consultations
Laboratory Testing - $35 Text Consultation
Imaging Order (X ray, CT Scan , MRI) - $35 Text Consultation
12
Which service do you need?* This field is required.
Metabolic Health/Weight Loss & GLP-1 — pricing per plan selected (Starting at $142/month)
Long COVID Recovery - $250 Initial Consultation, $125 Follow Up Consultation
Hormone Therapy (HRT) - $250 Initial Consultation, $125 Follow Up Consultation
Gut Health & Metabolic Reset - $250 Initial Consultation, $125 Follow Up Consultation
Urgent Care - $35 Text Consultation - $65 Video Call Consultation
Virtual DPC Physician - Primary Care (Text2MD Annual Membership Only) $350/Year - Unlimited Text Consultations
Medication Refill - $35 Text Consultation
Laboratory Testing - $35 Text Consultation
Imaging Order (X ray, CT Scan , MRI) - $35 Text Consultation
13
Are you requesting a medication or refill that is being used off-label (for a use not specifically approved by the FDA)?* This field is required.Examples of off-label use include treatment for conditions such as COVID-19, cancer, or other uses not specifically approved by the FDA.
YESNO
14
Are you requesting a GLP-1 Refill?* This field is required.Semaglutide or Tirzepatide any form commercial or compounded
YESNO
15
What type of consultation do you prefer?
Text Messaging ($35)
Video Call ($65)
I’m not sure — I’ll let the doctor recommend
16
All requests to start or refill an off-label medication require a scheduled video consultation before prescribing.

Because off-label use involves medications being used for conditions not specifically approved by the FDA, an appropriate medical evaluation is necessary to review your health history, current medications, potential risks, benefits, and alternative options, and to ensure the treatment remains safe and appropriate for you.

This process also allows for informed consent, proper documentation, and compliance with current regulatory and safety standards. Our priority is to protect your health while practicing responsible, evidence-based prescribing.

Please click on the link below to schedule the consultation.

https://text2md.com/follow-up-consultation-with-dr-antonatos/

Password: txtmd
17

Initial Consultation with Dr. Antonatos - Booking Provided by Healthie
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