Telemedicine for Weight Loss & Wellness

Dr. Angela Straface is a board-certified MD and 25+ year Frontline Doctor available in every state. Through telemedicine, we can offer convenient and affordable healthcare services to patients.

First Name

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Date of birth:

Current weight

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Prior surgeries?

Do you have a known heart condition?

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If yes, please explain your heart conditions:

Do you have a family history of heart conditions?

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If yes, please explain your family history of heart conditions:

Are you currently pregnant or breastfeeding?

Do you have or had in the past, any drug addiction?

Any existing medical issues?

Are you taking any medications? If yes, please list.

Any allergies to medications?

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Do you or have you had a blood pressure reading above 140/80?

Do you or have you had in the past a heart rate over 100?

Do you or have you had in the past any cardiovascular issues?

Are you currently taking medications from another provider?

If yes, what medications are you taking?

Are you taking any medications for ADD/ADHD?

Please list all medical procedures, including surgeries. Please provide the date of treatment and the outcome.

Have any of your family members had any of the following: heart, kidney, or thyroid issues, cancer, lung disease, stroke, or any other major health issue?

Describe your exercise habits: do you walk, run, go to the gym, or do weight training?

What do you eat for breakfast, lunch, and dinner?

Do you eat fast food often?

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How are your sleeping habits?

Do you smoke cigarettes? If yes, how many a day?

Do you drink alcohol? If yes, how often?

Have you seen one or more of these providers in the last 5 years?

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Cardiologist
Neurologist
Oncologist
Endocrinologist
Pulmonologist
Gastroenterologist
None

Women Only* Do you have any issues with your menstrual period? (bloating, cramps, hot flashes, night sweats)

I understand that a medical consultation is necessary to rule out any conditions that would disqualify me from the program. I understand there is no guarantee for the effectiveness of weight loss medications, vitamin shots, or supplements.

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Prior to my treatment, I have fully disclosed any medical conditions, diseases, illnesses, and medications.

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I understand that any weight loss medication or supplement is absolutely contraindicated during pregnancy and breastfeeding. I will stop the medication immediately and notify my provider. I also agree to stop any weight loss medications if I am currently trying to get pregnant.

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I agree to immediately report any problems that might occur to my provider during the treatment of the program. I further understand that not complying with the dosage recommendations and dietary restrictions could increase the risks and alter my results from the program. If I don't follow these recommendations and restrictions, I agree to release Feel Ideal 360 and their staff from any liability arising as a result of this.

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I request the use of weight loss medication, along with a strict dietary purpose for weight loss. I understand that as part of this program, I will be in a limited physical connection to the program and receive support virtually.

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I understand that I may quit the program at any time. If adverse side effects do occur, I understand that I must contact Feel Ideal 360, the provider and staff immediately. If I experience an emergency situation, I understand that I need to go to an emergency facility.

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I understand that I must notify my provider immediately if there are any changes in my medical history, current medications, or any changes relevant to this treatment.

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I have read and fully understand the above terms. All my questions have been addressed to my satisfaction. I agree to release Feel Ideal 360, the provider, and staff from any liability associated with this treatment. In the event a dispute arises about the outcome of the treatment, I consent solely to arbitration as a legal means of settlement.

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If I fail to disclose any medical condition that I have, I release Feel Ideal 360, their providers, and staff from any liability associated with this treatment.

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Out-of-State patients: We are unable to use your personal pharmacy. We can only use specific pharmacies to ship your medication to your state. There may be additional costs for the consultation, medications, or any other product, including shipping.

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I understand that I must have an automatic arm blood pressure monitor, scale, picture ID, and payment information prior to my appointment. If I do not have these items available, I understand that I must reschedule my appointment for a later date. There are NO REFUNDS, NO EXCEPTIONS. There is a strict 24-hour cancellation policy.

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Upload a dated photo of your current blood pressure:

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What's the consent date?

Please accept the terms and conditions

I give consent for the points above.

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Referral

Who referred you so that we can thank them for their awesome support?

Medical Disclaimer

NEVER REQUEST AN ELECTRONIC VISIT FOR AN URGENT MEDICAL PROBLEM, CALL 911 INSTEAD.

Patient agrees to virtual e-visit service terms, privacy policy, and charge for receiving a virtual visit from Dr. Straface at Feel Ideal 360.

Requests for e-visits must be confirmed and scheduled by our office prior to the e-visit. Prior to the visit please fill out our medical questionnaire. After reviewing your information, or during the e-visit it may be determined that your problem is too complex for an e-visit session. In that case our office will schedule you for a traditional office visit and your e-visit fee will be applied to the patient balance related to your office visit. Our physician appropriately documents the virtual e-visit, including all pertinent communication related to the encounter, in the patient’s medical/health record. The physician has a defined period of time within which responses to a virtual e-visit request are completed. During the virtual e-visit, the physician may make recommendations, provide medical advice and/or prescribe, refill or recommend medications. The physician may suggest the patient receive additional care, examination, testing and/or treatment at a medical facility in-person. If necessary, the physician may also suggest that the patient receive care in an emergency room. Communication during an e-visit may be exchanged via teleconference, landline phone, cellular phone and online chat per the State of Texas. By requesting an e-visit you acknowledge that personal health information will be communicated. A virtual e-visit may include the total interchange of online inquiries and other communications associated with this single patient encounter, subject to determination of the physician. As with any medical service, decision, or treatment, there are risks; and, an e-visit is no different. Because this visit is electronic and not in person, you acknowledge that the risk may be greater than a traditional office visit, and by requesting the visit you agree to accept the outcome-even if it is undesirable. Also, in the unlikely event that we are unable to attend to your telemedicine appointment, please be aware that a 3% processing fee will apply should a refund be requested. In addition, you agree to abide by our office's routine policies including any policy related to litigation. I acknowledge I am paying for a telemedicine consult with the physician and the outcome will be based solely on the physician's medical discretion and the fee is non-refundable.

Signature

I acknowledge and agree that I have read the Medical Disclaimer above and I am authorizing Dr. Straface to proceed with our telemedicine visit.

Date

Important:

You may inquire with your own insurance company about reimbursement. We do not take insurance at this time.
The consultation fee does not include the cost of the medication prescribed.
Also, if you are experiencing any technical difficulties with our automated processing form above please contact our office directly and one of our Feel Ideal 360 Team members will assist. Thank you! Phone: 972-656-1200

In the event that my treatment plan includes shipped material, I understand Feel Ideal 360 is adding insurance to my order through USPS or FedEx to cover the cost of any loss or damage to my order while shipping. If my package is damaged, lost, or stolen, I will file a claim with USPS for financial reimbursement. Feel Ideal 360 is NOT responsible for delayed, damaged, lost, or stolen packages, and will NOT be reshipping delayed, damaged, lost, or stolen packages at this time.

Please check the box below to agree:

I agree

Billing Address

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Sub Total

$125.00

TOTAL

$125.00

Payment Method

Credit Card - Square

Telemedicine for Weight Loss & Wellness

We've received your Telemedicine Weight Loss and Wellness Appt Order