Telehealth Form

Great News — You’re Pre-Approved!

To finalize your submission and have your information reviewed by the doctor, please complete the

$19.99 consultation fee below.

Once payment is completed, your intake will be immediately submitted for physician review.
IF APPROVED-

You selected SEMAGLUTIDE, your CARD WILL BE CHARGED for $299/mo.
IF APPROVED-

You selected TIRZEPATIDE, your CARD WILL BE CHARGED for $399/mo.
Telehealth & Treatment Consent: By signing below, I acknowledge that my medical evaluation and any potential treatment will be provided via telehealth, including an asynchronous review of the health information I have submitted. By signing below, I consent to receive telehealth evaluation and treatment from STL Medical Weight Loss, LLC, including review of the health information I submit. I understand telehealth has limitations compared to in-person visits and is not appropriate for emergencies. I certify that the information I provide is accurate and understand that approval for treatment or prescriptions is determined solely at the discretion of the licensed medical provider. I acknowledge that weight loss medications, including Semaglutide or Tirzepatide, may have risks and side effects, and that some medications may be compounded by a licensed compounding pharmacy. If approved, I consent to treatment as prescribed and agree to report any adverse effects. By signing this I am opting into SMS messaging from STL Medical Weight Loss, LLC, I agree to receive text messages related to appointments, telehealth updates, prescriptions, billing, and wellness updates; message frequency may vary and message/data rates may apply. I may opt out at any time by replying STOP or receive help by replying HELP, and SMS consent is not required to receive services. I acknowledge the selected medication(s) and associated pricing listed above. I understand that the consultation fee is separate from the cost of medication. If approved, I authorize my payment method to be charged for the approved medication(s) that you select above in the form and in accordance with the pricing presented above. If I am not approved, no medication charges will be processed.*
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