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Weight (lbs)*: Height (in)*:

Weight (lbs)*:

Height (in):

Select Appointment Time:

Patient Medical History

Please select all medical conditions:

Please list all your current medications (prescribed, over the counter, or herbal supplements):

Drug History*:

Yes

Please list all medication allergies (if any) :

Last HbA1c Reading(if available)

Blood Sugar Reading(if available)

Sugar Tested at Time of

Last blood pressure reading (if available) :

mmHg

Blood pressure reading date (if available) :

Last physical exam (if available) :

Primary Care Physician Name :

Billing Information

Your card will be billed $75 + $20 (shipping/handling of medications)

Is your billing address the same as your mailing/shipping address?*

Yes

Your Billing Address*

Credit Card Number*:

CVV*: Month and Year of Expiry* (mm/yyyy) :

CVV*:

Month and Year of Expiry* (mm/yyyy) :

Consent for Treatment

I have read and agree to the Telehealth Consult Consent Form* and the following: I have read and agree to the Telehealth Consult Consent Form* and the following:

I consent to receive evaluation, treatment, and care via telehealth by  MediSteps and by their employed, contracted, and affiliated healthcare providers. I authorize MediSteps to work with my other healthcare providers on my behalf.

I agree to consult with a medical provider at MediSteps. I agree that if medication is prescribed, I will take the medication only as prescribed. If I experience any side effects, I will inform MediSteps immediately.

I will inform MediSteps about any new medical condition and/or new medication and side effects or issues with the medications.

I do not have a history of cardiovascular disease, pulmonary hypertension, severe or uncontrolled high blood pressure, overactive thyroid, glaucoma.

I am not pregnant or breastfeeding.

I do not have a history of drug abuse.

MediSteps is not liable for any damaged or lost medications.

I am hereby initiating and agreeing to receive telehealth services including, without limitation, telehealth visits, e-visits, and virtual check-ins from MediSteps at the cell phone number and email address that I have provided in my patient registration information. These visits may include texting, email, telephone, video conference, or other technologies as available.

I accept that a telemedicine encounter will not be the same as a direct patient/provider visit due to the fact that the patient will not be in the same room with the healthcare provider and I accept this difference in experience and quality.

I understand and acknowledge any risks, benefits, and practical alternatives to a telehealth consultation.

I understand that my healthcare provider or I can discontinue the telehealth consult/visit if it is felt that the technological connections are not adequate for the situation.

In accordance with HIPAA privacy rules, some of my information may be shared for scheduling and billing purposes or among physicians, their staff, and their colleagues for the purpose of enhancing patient care, diagnosis, and therapeutic options.

My signature below evidences my agreement to all of the terms set forth in this consent. I understand that this consent is effective on the date signed below and that I may revoke this consent in writing. My revocation will not be effective for actions already taken by MediSteps or that are in progress and will only be prospectively effective.

I have read and understood this form and I am the patient to sign this consent.

By typing my name and date below, I hereby acknowledge that I understand and consent to the above terms:

Signature*
Signature Date :

Our Online Weight Loss Clinic is Available NOW

Our virtual program includes:

Patient Information

Patient Medical History

Billing Information

Your card will be billed $75 + $20 (shipping/handling of medications)

Consent for Treatment