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First Name

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Date of Birth *

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Information Accuracy *

I confirm that all the information I provide here, and throughout the titration process, is honest and accurate. I also agree to inform the clinic if there are any changes to my health conditions or medications.

Next Steps Confirmation *

We will now progress your file to our clinical team for review. Please note that we may need to contact you or your other healthcare providers for further information before you can start titration. You may also need to undertake further tests or observations, such as an ECG or additional blood pressure readings. This process ensures your safety and is a required step before we can book your first titration appointment, and prescribe ADHD medication to you.

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