Telehealth Consultation Booking

First Name *

Last Name *

Email *

Phone *

Address *

City *

State *

Postal code *

Date Of Birth (MM/DD/YYYY) *

Biological Sex *

Male

Female

Do you have any allergies to medications? Which? *

Please list all of your current medications with dosages

Please list any past surgeries

Height *

Current Weight *

Goal Weight *

How important is it to you to accomplish your health goals at this time in your life? *

How much are you currently investing into your health monthly?

If you were grading yourself A through F how would you grade yourself in these areas in the last few months? (standard academic grading scale, A+ being the best, F being failing)

On a scale of 1-10 (10 being the most comfortable) how comfortable are you with needles and injections?. *

Are there any specific questions you would like answered during your consultation? *

Payment is due at the time services are rendered. According to FDA Policy Sec. 460.300, I acknowledge that I cannot return or receive refunds for medications and/or injections once the medications/injections leave the office regardless of effectiveness or possible adverse reactions. All service fees paid are FINAL. * * *

I understand

Payment Authorization Form: I understand that I will be billed $75 for this telehealth consultation. If I consent to proceed with weight loss treatment upon completion of this telemedicine consultation, I acknowledge that my credit card on file with Gard Wellness Solutions will be charged immediately for the cost of the medication and shipping charges. This DOES NOT imply that the medication will ship the same day. I will allow up to 5-7 business days for fulfillment and delivery of my medication. I will receive a UPS or USPS tracking number via email when my package ships. While Gard Wellness Solutions will assist with claims filed with UPS or USPS, I understand that Gard Wellness Solutions is not liable for shipping delays or damages beyond their control. * *

I understand

No Show and Same Day Cancellation Policy: To ensure efficient and timely care for all patients, we have a policy in place regarding appointment no-shows and late cancellations. If you need to cancel, please notify us at least 24 hours in advance via phone, text or email. This allows us to accommodate other patients that are in need of medical care. A "No Show" refers to missing a scheduled appointment, while a "Same Day Cancellation" is canceling less than 24 hours before the scheduled appointment. A fee of $75 will be charged for a No Show or Same Day Cancellation. It will be assessed immediately after the allotted appointment time has lapsed. *

I understand

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Telehealth Consult Booking (Step 1 Of 2)