Provider Sign-up

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Conclusion

Sign-up for the 14-day Free Trial

Please fill out the information requested to sign up for the free trial. You will not be charged during your 14-day free trial, and you can cancel anytime before the trial period ends. If you choose to continue using Adaptive Telehealth after the trial period, you will automatically be signed up for our Video Essentials Package and will be charged $14.00 per month, per user license.

Please enter your details here:

First Name: *
Middle Name:
Last Name: *
Country: *
State/Province: *
Street/City: *
Address: *
Zip/Postal Code: *
Email: *
Phone Number: *
Number Of Users:

Card Number: *
Name on the card, if different:
	Month / Year *
Card Expiration: *	/
CVV: *
Amount:	0.00 USD
Your credit card will be billed 0.00 USD per month.