Name
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Date of birth
Email
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Phone
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Step 1 – Your Primary Goals
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Routine preventive care and annual visits
Management of chronic or long-term conditions (thyroid, blood pressure, diabetes, etc.)
Hormone balance or optimization (perimenopause, menopause, testosterone)
Gut health, food sensitivities, or detoxification
Weight management or metabolic reset
Aesthetic or skin rejuvenation treatments (injectables, facials, laser, micro needling)
A combination of the above
Step 2 – How Do You Prefer to Work With Your Provider?
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Short, focused visits for medication or refills
Longer, in-depth visits that look for root causes
Same-day or next-day access for urgent needs
Ongoing support and accountability
Personalized beauty, skin, and aging-prevention plan
Step 3 – Your Current Health Complexity
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I’m generally healthy and want convenience and access
I manage one or two stable conditions
I have multiple systems involved (gut, hormones, thyroid, adrenals, etc.)
I’ve seen multiple providers without clear answers
I’m already in (or completed) an Astra wellness or hormone program
Step 4 – Desired Level of Access
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Annual or semi-annual visits only
Monthly or quarterly visits for ongoing optimization
Unlimited messaging and fast response times
Same-day access for urgent needs
Regular skin and aesthetics maintenance (monthly or quarterly)
Step 5 – Aesthetic Interests ✨
What treatments or services are you most interested in?
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Facials or HydraFacial
Laser skin rejuvenation or resurfacing
RF micro needling (Genius/LaseMD)
Botox/Dysport or dermal fillers
PRF/PRP or regenerative skin treatments
Monthly skincare maintenance or product savings
Body contouring or fat reduction treatments
Combination of medical + aesthetic wellness
How often do you typically receive (or want) aesthetic treatments?
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Every month
Every 2–3 months
Twice a year
Only as needed
Never
Are you interested in banking monthly funds toward future treatments?
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Yes — I’d love to build monthly credit (Beauty Bank)
Maybe — I’d like to see options
No — I’ll pay per service
Step 6 – Optional Add-Ons
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Add primary care visits and sick care
Add hormone management
Add functional medicine testing and nutrition plans
Add Beauty Bank/aesthetic membership benefits
Add supplement and peptide discounts
No Add-Ons/Not Sure
Submit
