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Telemedicine Consultation Request Form
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Select your state
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Full Name
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First Name
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Date of Birth
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Cell Phone Number
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Email Address
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6
How did you heard about our services?
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7
Telemedicine Informed Consent, HIPAA NOTICE OF PRIVACY PRACTICES And Refund Notice
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Signature
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I have read and agree with Text2MD Telemedicine Informed Consent, HIPAA NOTICE OF PRIVACY PRACTICES And Refund Notice
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9
Which service do you need?
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Weight Loss & GLP-1
Long COVID Recovery
Hormone Therapy (HRT)
Gut Health & Metabolic Reset
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10
Booking Provided by
Healthie
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11
Initial Consultation with Dr. Antonatos - Booking Provided by
Healthie
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