First Name

Last Name

Phone *

Email *

Date of birth *

State (2-letter abbreviation) *

Which virtual service are you starting? *

What is your primary wellness goal? (A licensed provider determines treatment) *

Which supply schedule do you prefer? (Provider approval required) *

12-week supply — Recommended for convenience and fewer refill steps

4-week supply — More flexibility with more frequent refill review

Please have the clinic help me choose

Supply preference

If choosing GLP-1, which medication path interests you? *

Tirzepatide

Semaglutide

Provider help me choose / Not applicable for peptide therapy

GLP-1 medication path

Medication payment authorization *

By checking this box, I authorize Healthwise Medical and Aesthetics to send me a secure payment request for medication only after a licensed Qualiphy provider approves a prescription. I understand medication is billed separately from the $99 monthly membership, approval is not guaranteed, and charges vary by medication, dose, and supply length. I consent to transactional messages about exams, payment, refills, and shipping.

Medication authorization

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications. Message frequency may vary. Message & data rates may apply. Reply HELP for help or STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, and product updates. Message frequency may vary. Message & data rates may apply. Reply HELP for help or STOP to opt out.