Vale Wellness — New Patient Registration - Register with Vale Wellness so our team can create your patient record in Prescribery. We will then email your individual medical intake link. This registration does not replace your medical intake or confirm treatment eligibility.

Vale Wellness

First Name

Middle Name

Last Name

Nickname

Date of Birth

Height

Include feet and inches, or centimeters.

Weight (lb)

We will send your personal medical intake link to this address.

Mobile Phone

Postal Code

Country

United States, or specify another country.

State

District

City

Address Line 1

Address Line 2

Preferred Language

English, or specify your preferred language.

Emergency Contact Name

Emergency Contact Email

Emergency Contact Age

Emergency Contact Phone

Shipping address is the same as my home address

If checked, leave the shipping fields below blank.

Shipping Postal Code

Shipping Country

Shipping State

Shipping City

Shipping Address Line 1

Shipping Address Line 2

Insurance Provider

Policy Number

Referred By

Additional Notes (Optional)

Please share any additional information or questions you would like our team to review.

Upload Lab Results (Optional) Upload your lab results or supporting documents here. You may attach multiple files. Please make sure your name and the test date are visible on each report.

Add file

Please upload a file

Your information will be encrypted.