The Forest Lounge Medical Center | Initial ADHD Telehealth Consultation Agreement

The Forest Lounge Medical Center offers convenient and affordable healthcare services through telemedicine. This mode of healthcare delivery is particularly suitable for non-emergency situations.

All Staff and Medical Providers at The Forest Lounge are guided by the American Medical Association’s Code of Medical Ethics and we adhere deeply to the ethos that “medicine is practiced one patient at a time and each patient has individual needs and vulnerabilities.”

THE INITIAL ADHD TELEHEALTH CONSULTATON INCLUDES:

The Cost of the Initial Telemedicine Consultation includes Bloodwork*, Review of your Medical History and a Discussion about your Health and Wellness Goals with a Qualified Forest Lounge Medical Professional.

*If you have had Bloodwork done within the last year, immediate Bloodwork is not required unless a Forest Lounge Medical Professional determines otherwise. We will carefully assess any recent bloodwork you have undergone to determine if additional tests are necessary for Semaglutide Treatment. Patients will not incur any additional fees for these assessments. These tests are commonly comprised of an obesity lab panel, evaluating CBC (complete blood count), CMP (comprehensive metabolic panel), lipids (cholesterol levels), A1C (glycated hemoglobin for diabetes), TSH (thyroid-stimulating hormone), and insulin levels.

ADHD PROGRAM DETAILS:

NO INSURANCE SURPRISES. NO CO-PAY. NO HIDDEN FEES:

After the Initial Telemedicine Consultation and Upon Approval by a Qualified Forest Lounge Medical Professional, Patients can expect:

One Cost. Billed Monthly. No Contracts. Pay as you go. No need to worry about Cancelling a Subscription or getting that surprise Medical Bill. Straightforward is what our Patients prefer.

INITIAL ADHD CONSULTATION & FIRST MONTH UPON APPROVAL:

$199 Includes:

+ Initial consultation with qualified provider
+ Prescription for up to 30 days of medication***
+ Full Access to all TFL dietary, supplement education and services
+ Urinalysis drug screen and any other pertinent lab studies
+ Customized Patient Portal
+ Close follow up with provider in the first 30 days of treatment
+ Monthly Check In & Follow Up Calls
+ Secure HIPAA Compliant Online Medical Management
+ Coordination of Prescriptions Through Qualified Partner
+ 10% discount on IV Therapy Packages
+ 5% discount on FullScript pharmaceutical high-grade supplements

1 MONTH FOLLOW-UP • ADHD CONTINUATION OF CARE:

$99 Includes:

+ Follow-up consultation with qualified provider
+ Prescription for up to 60 days of medication***
+ Full Access to all TFL dietary, supplement education and services
+ Customized Patient Portal
+ Monthly Check In & Follow Up Calls
+ Secure HIPAA Compliant Online Medical Management
+ Coordination of Prescriptions Through Qualfied Partner
+ 10% discount on IV Therapy Packages
+ 5% discount on FullScript pharmaceutical high-grade supplements

3 MONTH FOLLOW-UP • ADHD CONTINUATION OF CARE:

$99 Includes:

+ Consultation with qualified provider
+ Prescription for up to 90 days of medication***
+ Full Access to all TFL dietary, supplement education and services
+ Urinalysis drug screen and any other pertinent lab studies
+ Customized Patient Portal
+ Monthly Check In & Follow Up Calls
+ Secure HIPAA Compliant Online Medical Management
+ Coordination of Prescriptions Through Qualified Partner
+ 10% discount on IV Therapy Packages
+ 5% discount on FullScript pharmaceutical high-grade supplements

PATIENT INFORMATION:

First and Last Name*

First NameLast Name

Date of Birth*

Date

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Please Provide your Height and Weight*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

YOUR FIRST TELEMEDICINE CONSULTATION:

WE WILL CONTACT YOU WITHIN ONE BUSINESS DAY TO SCHEDULE YOUR INITIAL CONSULTATION USING THE PHONE NUMBER YOU PROVIDE. IF YOU HAVE A SPECIFIC DAY THAT WORKS BEST FOR YOU, WE WILL ALSO MAKE EFFORTS TO CALL YOU DURING YOUR PREFERRED DAY INDICATED BELOW.

Best Phone Number to Reach You*

Please enter a valid phone number.

Preferred Days & Times Reach You

TERMS OF SERVICE AGREEMENT:

Requests for telehealth must be confirmed and scheduled by our office prior to the telehealth visit. Prior to the Initial ADHD Consultation, I agree to fill out The Medical Intake Form which will be emailed upon completion of this Agreement.

I, {firstAnd}, acknowledge I am paying for a telemedicine consultation with a Qualified Forest Lounge Medical Professional and the outcome will be based solely on the Medical Professional's discretion. The Initial ADHD Consultation fee is non-refundable.

Patients First and Last Name (Print)*

Today's Date*

Date

Patient Email*

example@example.com

Please sign below. I acknowledge and agree that I have read the Initial ADHD Consultation Agreement. I authorize The Forest Lounge to contact me to schedule a telemedicine visit once payment is received below.*

CHECK OUT:

Forest Lounge Services*

Initial ConsultationThe Cost of the Initial Consultation includes list above and a Discussion about your Health and Wellness Goals with a Qualified Forest Lounge MP.

$199.00 Quantity
Item subtotal:$0.00

1 Month Follow-Up to Continue TreatmentThe Cost of the 1 Month Followup includes the list above and a Consultation with a Qualified Forest Lounge MP.

$99.00 Quantity

3 Month Follow-Up to Continue TreatmentThe Cost of the 3 Month Followup includes the list above and a Consultation with a Qualified Forest Lounge MP.

$99.00 Quantity

Enter coupon

Total

$0.00

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

After processing, a receipt will be sent to your email. Please feel free to call us with any questions.

THE FOREST LOUNGE MEDICAL CENTER
173 E. Laurel Ave. • Lake Forest • IL • 60045 • Phone: 224.899.2000 • Fax: 224.899.1999 Email: info@myforestlounge.com • Website:www.myforestlounge.com