MOUNJARO TELEMEDICINE INTAKE FORM

Dr. Angela Straface is a board-certified MD and 25+ year Frontline Doctor. Through telemedicine, we can offer convenient and affordable healthcare services to patients. Telemedicine is an excellent option for non-emergency situations.

Please fill out our questionnaire below. We do kindly ask that all information is correct including pharmacy numbers and fax numbers so that your prescription is not delayed. Thank you!

Please read these terms carefully and agree to the terms below.

Not to be used in pregnancy, or by those who might become pregnant- sexually active women should use contraception.

RELEASE FROM MEDICAL LIABILITY AND MALPRACTICE CLAIMS: 

I acknowledge that off-label treatment for weight loss poses numerous personal and professional risks to practitioners who prescribe these alternatives, unapproved treatments, that, though presumed and believed to be safe and effective based on the best available evidence, may in fact be harmful and could cause severe disability and even death, which can in fact occur with any and all medical treatments in some percentage of patients, but physicians involved in these negative outcomes are shielded from liability when their peers agree their treatments were warranted. This is not the case with treatment of weight loss. Where prescribing practitioners are acting outside the bounds of medical establishment consensus, therefore in order to obtain treatment that is not physician peer, FDA, NIH or CDC approved, but may nevertheless be beneficial, I agree to release Dr. Angela Straface and all her associates from all medical liability and malpractice claims related to any and all care, including but not limited to weight loss treatment or injections.

YOU MUST AGREE TO THE TERMS MENTIONED ABOVE IN ORDER TO CONTINUE.

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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. 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.

Important:

  • You may inquire yourself 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
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Sub Total
$125.00
TOTAL
$125.00

We've received your Mounjaro Intake Form

Hello,

We received your intake form for a Mounjaro telemedicine appointment.  While we try our best to facilitate all telemedicine requests the same business day, please allow 24 hours for Dr. Straface to contact you. Dr. Straface will call you at her first available opportunity.  To not delay the call, please be sure your phone settings for unknown/spam blockers are turned off. 

SATURDAY/SUNDAY INTAKES WILL BE CALLED BACK WITHIN 48 HOURS.  

Please email us should you need additional assistance.

Dr. Straface and the 

Feel Ideal 360 team

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