Value Med - Sign Up Form

Tell Us About Yourself
Name*

First NameLast Name
Cell Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Birthdate*

MonthDayYear
Date
Gender*

MaleFemaleN/A

Are you in our service area?
ADHD treatment is only available in: Alabama, Alaska, Arizona, Arkansas, California, Colorado, Florida, Maryland, Michigan, Missouri, Nebraska, New Hampshire, Ohio, Virginia, and Washington.

Weight Loss and GLP-1 treatment is only available in: Alaska, Arizona, Colorado, Connecticut, Florida, Illinois, Indiana, Iowa, Maryland, Missouri, Nebraska, New Hampshire, New Jersey, Ohio, Rhode Island, South Carolina, Utah, Virginia, and Washington.
What state do you live in?*

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Choose a Value Med service

My Products*

Value Med - Weight LossWith our GLP-1 Weight Loss Service. No insurance is needed. This is a monthly medical service plan with medication costs built-in. You may cancel anytime.

$250 for each month

Value Med - ADHD ServiceWith our ADHD Service, you'll meet with one of our doctors to determine the appropriate treatment. This is a monthly medical service plan. You may cancel anytime.

$99 for each month

Value Med - Men's Health Service (TRT, ED)With our Men's Health Service, you'll meet with one of our doctors to determine the appropriate treatment. This is a monthly medical service plan. You may cancel anytime.

$84 for each month

Value Med - Peptide Therapy ServiceWith our Peptide Therapy Service, you'll meet with one of our doctors to determine the appropriate treatment. This is a monthly medical service plan. You may cancel anytime.

$84 for each month

Value Med - Rapamycin ServiceWith our Rapamycin Service, you'll meet with one of our doctors to determine the appropriate treatment. This is a monthly medical service plan. You may cancel anytime.

$84 for each month

Enter coupon

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Tell Us About Yourself

Are you in our service area?

Choose a Value Med service