Treatment request

Patient details & card authorization

Square securely saves your card. Nothing is charged today. The medical assessment opens next.

Protected connection

Patient information

Contact and identifying details for your consultation.

First nameLast nameEmail addressPhone numberDate of birth

Delivery & billing address

Square uses this address to verify the card. It is also the delivery address if treatment is approved.

Street address

Apartment or unit (optional)

City

StateZIP code

Securely save your card

Enter the card directly in Square's secure form. The amount due today is $0.00.

Your full card details remain with Square

VitaCare does not receive or store the full card number, expiration date, or security code. Square returns only secure references, the card brand, and last four digits.

Connecting to Square… We automatically retry temporary connection failures.

Acknowledgments & one-time authorization

Required before Square can securely save the card.

I confirm that the patient is 18 years of age or older.I understand that saving a card creates a treatment request, not a prescription. Prescribing and dispensing depend on assessment, consultation, and approval by a licensed clinician. I have read the privacy policy.I authorize Square to save my payment method for VitaCare and authorize VitaCare to make one charge of up to $349.00 only if a licensed clinician approves the selected treatment. I understand that nothing is charged today and that I may withdraw this authorization before the charge by messaging us through WhatsApp.