Value Med - ADHD 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
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SMS & Email Commnications

By providing a telephone number and submitting this form you are consenting to be contacted by SMS text message. Message & data rates may apply. You can reply STOP to opt-out of further messaging.

Terms of Service
HIPAA, Confidentiality, Privacy, and Electronic Commnications

We take your privacy very seriously. All of our systems are setup with encryption. In order to be most efficient we need to make use of modern communication tools including email, cell phone calls, zoom and other video conference tools, and text messages. By continuing to use our service you agree to receive communicate through these common forms of electronic communication and you'll join us in making every effort to keep these communications secure.

Accuracy of Information

Information you provide will be compared to prescription databases that are maintained by the government, insurance companies, and pharmacy networks. Inaccuracies and/or inconsistencies may result in refusal of treatment.

Billing Terms

You may cancel service at anytime to prevent further monthly charges.

Your initial ADHD appointment includes a comprehensive evaluation, which is essential for diagnosing and planning your treatment. This comprehensive evaluation costs an additional $250, but we defer and waive this fee for most patients. Here's how it works:
- If you do not receive a diagnosis, the additional $250 fee is waived.
- If you receive a diagnosis and stay on the service for at lest three months, the additional $250 fee is waived.
- If you receive a diagnosis and cancel within the first three months, you will be charged the previously deferred $250 evaluation fee. This is in addition to the monthly fees already paid.
We reserve the right to charge a processing fee of $40 if you cancel after your intake is processed.

Cancelled or missed appointments (without 24 hour notice) will be subject to a $40 rescheduling fee.

Refunds for fees already paid cannot be provided once consultations and/or treatment has begun for any given billing period.

Please click NEXT to agree and continue signing up

Choose a Value Med service

My Products*

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.

$119 for each month

Enter coupon

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

Should be Empty:

Tell Us About Yourself

Terms of Service

Choose a Value Med service