Before you begin

This service is not for emergencies. Submission does not guarantee treatment or a prescription.

Complete the form while physically located in a state where our clinician is licensed.

Confirm your visit

Please confirm that you understand this telehealth visit is for:

If you need care for another reason, return to the previous page and review the available telehealth visit choices.

I understand and want to continue with this visit type.

Who is this visit for?* Myself My dependent child

Are you a 24Sculpt Health member?

Identity verification

Before continuing, provide a clear photo of your government-issued photo ID and a current selfie. For a dependent visit, upload the parent or legal guardian’s ID and selfie.

Choose Use camera to open the secure Firebase camera page in a separate window, or choose an existing image from your device.

Government-issued photo ID* Or upload an existing ID image Show the entire front of the ID with the text readable.

Current selfie* Or upload an existing selfie Face the camera directly with your full face visible.

ID preview

Selfie preview

I confirm that the ID is mine and the selfie is a current image of me. I am either the patient or the parent/legal guardian completing this intake for the dependent patient.

Return to visit choices

Dependent information

You indicated that this visit is for you. No dependent information is required.

Emergency screening

Select every item that applies.

Patient information

First name* Last name* Date of birth* Sex assigned at birth* Mobile phone* Street address* Address line 2 City* Home state* ZIP code*

Email address*

Email not verified.

Current physical location

Telehealth eligibility is based on the state where you are physically located during the visit.

Current state* I confirm that I am currently physically located in the state selected above.

Visit details

Visit type:

When did the symptoms begin? Is there any other information you would like to share with your provider?

Medical information

Please list any medications you are allergic to.* Please list all of your current medications or supplements and doses.*

Pregnancy status

Height: feet* Height: inches*

Body weight*

lbs

Preferred pharmacy

Pharmacy name* Pharmacy phone number* Pharmacy street address* Pharmacy city* Pharmacy state* Pharmacy ZIP code*

Consent and acknowledgment

Telehealth consent

I understand the limitations and risks of telehealth, that an in-person examination or emergency evaluation may be required, and that no diagnosis, medication, antibiotic, or other treatment is guaranteed.

I consent to receive telehealth care. I certify that the information provided is complete and accurate. I acknowledge receipt or availability of the Notice of Privacy Practices. I authorize routine contact at the phone number and email provided, understanding ordinary email or SMS may carry privacy risks.

Typed legal name* Date*

24Sculpt Health

Before you begin

Confirm your visit

Visit type not selected

Are you a 24Sculpt Health member?

Member login

Identity verification

Dependent information

Parent or Legal Guardian Attestation

Emergency screening

Emergency care required

Patient information

Current physical location

Visit details

Medical information

Preferred pharmacy

Consent and acknowledgment

Telehealth consent

Complete payment

Submission received