Telehealth Form
(No Phone Call or Video Visit Required- Based on Responses Below)
First Name
*
Last Name
*
Street Address
*
State
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
DC
City
*
Zip Code
*
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Current Weight (in lbs)
*
How much weight do you want to lose? (in lbs)
*
Please list any medications you take:
Please list any allergies
Medical History Select any Diagnoses that apply:
Diabetes
High Blood Pressure
High Cholesterol
Fatty Liver Disease
PCOS
Pre-Diabetes
Insulin Resistance
None of the Above
Do you have any personal or family history of Thyroid Cancer or MEN2
YES
NO
History of Pancreatitis
YES
NO
Pregnancy/breastfeeding/planning pregnancy
YES
NO
Any History of Stomach or Kidney Conditions (CKD, Chronic Kidney Disease)
YES
NO
Any History of Bariatric Surgery?
YES
NO
Do you take insulin or sulfonylureas like GLYBURIDE or GLIPIZIDE or GLIMEPIRIDE?
YES
NO
Have you had blood work/labs in the last 12 months.
*
YES
NO
If you answered YES, were there any abnormalities noted?.
*
YES
NO
Select the weight loss medication you are interested in:
*
Semaglutide - $199/mo LOW DOSE (0.25-1mg) - INTRODUCTORY PRICE
Tirzepatide - $299/mo - LOW DOSE (2.5mg-5.0mg)- INTRODUCTORY PRICE
Want to know more about GLP-1s? Dr. Joe Moleski 🩺 Answers all your questions in the video ⬇️
After signing below you will be prompted to complete a ONE-TIME $19.99 telehealth consult fee. Your submissions will not be reviewed unless this payment has been completed. Do you agree to proceed?
*
YES
NO
Signature: Telehealth & Treatment Consent, By signing below, I acknowledge and agree that my medical evaluation and any potential treatment are being provided via telehealth, including an asynchronous review of the health information I have submitted. I understand that no diagnosis or treatment is guaranteed and that approval is determined at the sole discretion of the licensed medical provider. I acknowledge that GLP-1 medications and other peptide-based therapies may carry potential risks, benefits, side effects, and alternatives. I understand that additional information is available upon request and that I may decline treatment at any time prior to approval. If approved, I consent to receive treatment as prescribed and agree to follow all medical instructions and promptly report any adverse effects or changes in my health status. I acknowledge and agree to the selected medication(s) above and associated pricing. I understand that the consultation fee is separate from the cost of medication. If approved, I authorize my credit card to be charged for the approved medication(s) above in accordance with the pricing presented. If not approved, no medication charges will be processed.
*
Submit
Should be Empty: