Value Med - GLP1 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

Terms of Service
ASYNCHRONOUS MEDICAL SERVICE

Our services are often delivered asynchronously, meaning you send messages/forms/requests/questions and our team (including medical doctors) review and respond.

You are entitled to schedule a live video consultation with our medical staff at any time if you prefer live service.

Asynchronous service is safe and legal. In most case our team will process your prescription same-day so that you receive your medication typically within 3-10 business days. Please monitor your email and phone (text and voice calls) as we may reach out to you with urgent questions regarding your care.

ASYNCHRONOUS BILLING

Our services are billed MONTHLY (every month) and these fees include the costs associated of doctor supervision, any appointments you may schedule, back-office processing, and delivery of your medication through our network of independent compounding pharmacy partners.

In many cases medication may be packaged to last longer than 4 weeks. Refills schedules may not align with monthly billing renewals. You are obligated to continue paying your monthly service fees for as long as you're on treatment, regardless of your refill schedule.

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. 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 missed appointment fee. Refunds for fees already paid cannot be provided once medication has been ordered.

Please click NEXT to agree and continue signing up

Choose a Value Med service

My Products*

Value Med - Semaglutude GLP1 Weight LossYou will receive GLP1 medication with the same active ingredient as Ozempic and Wegovy from one of our independent compounding pharmacy partners. This is a monthly medical service plan with medication costs built in. You may cancel anytime.

$250 for each month

Value Med - Tirzepatide GLP1 Weight LossYou will receive GLP1 medication with the same active ingredient as Mounjaro and Zepbound from one of our independent compounding pharmacy partners. This is a monthly medical service plan with medication costs built in. You may cancel anytime.

$450 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

Terms of Service

Choose a Value Med service