Complete Your Medical Intake for Review

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Medical History:*
Please check all that apply.

I understand my provider will review my labs, medical history, and medical intake sheet to make any medical recommendations and/or changes.

Agree to terms?*
I agree to the terms outlined here regarding my medical history, labs, and provider review.
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Upload a photo of your Driver's License or government issued ID below. This photo is required to be present in the electronic medical record in order for your provider to prescribe medications for you.
Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 5 MB.

I understand this kit is for emergency use only and is for my use only and not to be shared with anyone. If at all possible I agree to seek medical attention or telehealth consult with my provider before using any of the medications to ensure proper use and diagnosis.

I agree to a pharmacy consult with the dispensing pharmacy prior to accepting medication to review medications included and appropriate use of each. I also acknowledge that these medications may have adverse effects if used inappropriately or mixed with other medications prior to seeking medical professional attention.

Agree to Travel Kit Terms*

I understand that medications provided by Elite Health Online are for my personal use only and for no other purpose. I will not share, sell or trade medications.

I will safeguard my medications from loss or theft and will be responsible for their safekeeping. If I lose, break or misuse prescribed medications, I will not be given more medication until the appropriate date determined by the American Drug Association.

All medications utilized or sold within Elite Health Online include fees associated with medication management / oversight, and vary depending on the specific medication.

Elite Health Online has the right to dismiss me as a patient at any time if I do not abide by the conditions set forth in this agreement.

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Agree to Medication Terms*
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I agree not to share, sell, or gift:*
This field is for validation purposes and should be left unchanged.