Clone of Telemedicine Appointment

Telemedicine Consultation

All information is strictly confidential & HIPAA protected.
Full Name*

First Name Last Name Suffix
Birthdate*

MonthDayYear
Date (YOU MUST BE 21+)
Email*
example@example.com
Phone Number*
Please enter a valid phone number and double check to make sure it's correct. This is how we will call you to set up your video visit. Format: (000) 000-0000.
Current Address (ADDRESS MUST MATCH YOUR VIRGINIA ID).*

Street Address

Street Address Line 2

CityState (MUST BE VIRGINIA)

Postal / Zip Code
What is your medical diagnosis? Please include date(s) of diagnosis*
Please Upload any medical files and proof of medical diagnosis here

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What are your allergies? *
What are your allergies
What medications do you take?*
What medications do you take? Include over-the-counter medications, vitamins, and supplements
I do not take and am not currently prescribed any controlled medicines, such as stimulants (examples include: Adderall (amphetamine/dextroamphetamine), Vyvanse (lisdexamphetamine), or Ritalin (methylphenidate)), anxiety medicines (Xanax (Alprazolam), Valium (diazepam), Ativan (Lorazepam), or Klonopin (Clonazepam)), sleep aids (like Ambien (zolpidem), Lunesta (eszopiclone), or Sonata (zaleplon)), Neurontin (gabapentin), or pain medicines (like Percocet (Oxycodone-acetaminophen), Norco (hydrocodone-acetaminophen), or other opioid).*

No, I am not on any controlled medicationsYes, I currently take or have had a prescription for a controlled medication. IMPORTANT NOTICE: If you select this box, YOU MUST CONTACT OUR OFFICE BEFORE SUBMITTING THIS FORM. FAILURE TO DO SO MAY RESULT IN YOUR REQUEST BEING DECLINED. Certain controlled medications may affect medical eligibility, require documentation or coordination with the prescribing clinician, or result in delay or denial of certification, based on clinical judgment and applicable Virginia law and regulations. Submission of payment does not guarantee certification or approval
No, I am not on any of theseYes, I currently take or have taken one or more of these medications. IF YOU SELECT THIS OPTION: STOP. DO NOT CONTINUE. CONTACT OUR OFFICE BEFORE COMPLETING THIS FORM. Failure to do so will result in your consultation request being declined
Please share your past experiences, current knowledge level, and whether you’re new to this or doing a renewal. During your telemedicine visit, we’ll help you understand the risks and benefits.*

YES, I am a Virginia Resident and I have an unexpired Virginia licenseNo, I am not a Virginia resident and/or do not have a valid Virginia ID
Virginia Drivers License or State ID Number*
We must have this information to see you beginning December 1, 2025
Take Photo of Your Virginia Drivers License or Virginia State ID To Upload Here (Must be uploaded for us to meet with you)*
Yes, I authorize Simply Sweet Health, LLC DBA Elevated Certs to charge my card for today’s telehealth consultation. I understand that once the consultation occurs or certification is issued, the service is non-refundable. I understand that disputing this charge as fraudulent or unauthorized after I have requested and received services may be considered financial fraud and may be reported to the appropriate authorities or collection services if applicable.
Signature*

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Telemedicine Visit

Payment is for a professional telemedicine medical evaluation and associated administrative services only. Payment does not guarantee the issuance of a medical certification or any particular clinical outcome. All patients are evaluated individually based on medical history, clinical findings, and professional judgment, in accordance with applicable laws and standards of care.

$80.00

Total

$0.00

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Telemedicine Consultation

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