Patient Personal Details

Pharmacy Information

Amazon Pharmacy is our default and recommended pharmacy for B12 prescriptions.
Most patients pay just $4 per month if they are Amazon Prime members, or $8 for a 3-month supply.

Our clinic offers a 1 month subscription at $19.99 or a 3-month subscription for $59.95, which includes unlimited provider messaging and support.

If you wish to use a different pharmacy, please write it here; otherwise, we will use Amazon Pharmacy by default.

Patient Insurance Information

Medical History & Contraindications

Medications & Diet

Skin & Immune Health

Please read carefully: We want to help you in every way possible. Please answer the following questions truthfully and to the best of your knowledge. This information is strictly confidential and will only be used to provide you with the best possible care. In the future, if we need to work with your insurance or advocate for you, your answers may help us better support your medical needs.

 

Why We Ask: B12 may help directly or indirectly by boosting energy and positive thinking, lowering stress, and supporting a healthy weight—all of which can improve these conditions. Honest answers help us advocate for your care, especially if we use your insurance now or in the future.

Symptoms & Wellness Goals

Lab Requirements

Lab Requirement for B12 Prescription

For your safety and best results, we require a Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) from within the last 12 months before starting B12 therapy.

• If you have had these labs done within the last year, you may upload your results below, or email them to info@myewlc.com 
• If you do not have recent labs, or they are more than a year old, we will order them for you after your telemedicine visit. 
• You may also upload any other recent labs (such as B12, folate, thyroid, or diabetes labs) if available.

Please note: If you do not upload labs, you can email them to us at info@myewlc.com later, or we will order them for you after your visit.

 Safety & Other Concerns

Consent to Treatment, Communication, and Subscription Agreement

Please read and acknowledge the following statements:

1. Medical Consent
   I consent to receive vitamin B12 therapy under the supervision of a licensed healthcare provider. I understand that B12 is generally safe but may carry risks if I have certain medical conditions or allergies. I affirm that I have answered all health questions truthfully and to the best of my knowledge.
2. Laboratory Requirement
   I understand that a recent Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) are required before initiating B12 treatment. If I have not uploaded these labs, I acknowledge that they must be emailed or will be ordered for me.
3. Pharmacy Acknowledgment
   I understand that Amazon Pharmacy is the default dispensing pharmacy unless I have provided an alternative in the designated field.
4. Program Subscription
   I understand and agree to the auto-renewing nature of the selected B12 subscription plan (monthly or every 3 months). I agree to the corresponding charges unless I cancel in accordance with clinic policies.
5. Confidentiality & Data Use
   I acknowledge that my health information will be kept confidential in accordance with HIPAA. I understand my data may be used internally for care coordination, insurance support, or clinical follow-up.
6. Communication
   I consent to receive communications via email, phone, or secure messaging regarding my care, lab orders, reminders, and billing. I understand I can opt out of non-essential communications.
7. Program Eligibility & Limitations
   I understand that my eligibility for treatment depends on my medical history, lab results, and clinical judgment of the provider. Participation in this program does not guarantee prescription or results.

Signature Confirmation

By signing below, I confirm that I have read, understood, and agree to the terms outlined above. I consent to begin the Empowered B12 Program under the care of this clinic.

Payment & Subscription

Choose Your B12 Subscription Plan

We offer two flexible options for your B12 treatment:

• $19.99 per month (auto subscription)
• $59.95 for 3 months (auto subscription)

Cancellation Policy for Auto-Renewing B12 Subscription

Hassle-Free Cancellation – No Long-Term Commitment 

Our Empowered B12 Program is designed to be flexible and convenient. You may cancel your subscription at any time, with the following terms:

Monthly Plan ($19.99/month)

• You may cancel at any time prior to your next billing date to avoid future charges.
• If you cancel after you’ve been billed for the month, your subscription will remain active until the end of that billing cycle.
• No partial refunds are issued once the month has started.
• Provider support and messaging access continue through the end of the paid period.

3-Month Plan ($59.99 every 3 months)

• This plan is billed every 3 months unless canceled in advance.
• Cancellations must be made before the next renewal date to avoid future charges.
• Once a billing cycle has started, it is non-refundable. You will continue to have access to all services—including provider messaging and support—until the end of that cycle.

How to Cancel:

You can cancel at any time by:

• Emailing us at info@myewlc.com , or
• Replying to any clinic message with “Cancel my subscription,” or
• Using the cancellation link provided in your subscription confirmation email, if available.

Restarting Your Subscription:

You are welcome to rejoin the program at any time. A brief re-evaluation may be required to ensure safe and effective continuation of care.