SAPW Monthly Weight Loss with GLP-1 Included

Patient's Full Name*

First NameLast Name

Date of Birth*

MonthDayYear

Email*

example@example.com

Phone Number*

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Select one of the following Memberships:

Monthly Weight Loss with Semaglutide Included

$299.00 for each month

Monthly Weight Loss with Low Dose Tirzepatide or Combo Included

$299.00 for each month

Monthly Weight Loss with Tirzepatide Included

$525.00 for each month

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Credit Card

General Membership Terms and Conditions

Member authorizes San Antonio Prime Wellness (SAPW) to charge monthly membership fees to the credit/debit card provided. If the member’s credit/debit card has changed, the member must notify San Antonio Prime Wellness as soon as possible.
Members are responsible for attending their appointments or communicating with SAPW of any adjustments in their schedule.
Memberships are non-transferable and may not be shared; Any membership payments are non-refundable.
SAPW reserves the right to change clinic policies, regulations, and pricing at any time upon providing reasonable notice.
The member acknowledges this document as an agreement and will become legally binding upon its acceptance by SAPW.
The member acknowledges receipt of SAPW membership terms and conditions and has read, understands, and agrees to be bound by the terms and conditions as part of this agreement.
The member assumes full responsibility for services received at SAPW and shall indemnify SAPW, its affiliates, agents, and employees against any and all liability arising from services rendered.

Monthly Weight Loss Membership Terms and Conditions

Members receive compounded semaglutide or tirzepatide every 3 months, monthly weight loss, nutrition and exercise counseling, Inbody scan, and a MIC/B-12 or MIC/L-Carnatine intramuscular shot.
There may be unforeseen circumstances when a member needs to terminate their membership. Membership must be maintained while the patient is on weight loss medication. Therefore, SAPW requires a 3-month cancellation notice after latest prescription has been ordered.

I have read and agree to the terms of this agreement.*

I agree

Today's Date*

MonthDayYear

Signature - Your signature signifies your consents to the use and disclosure of your PHI by our office during treatment, billing, reimbursement, and medical office operations. You agree and consent that your PHI may be communicated to you via telephone or email (encrypted or unencrypted).*

When you click Submit, you allow your card to be charged now and for subsequent recurring monthly payments. Please contact the office when you need to update your card at 210-455-3309.

SAPW Membership Agreement

Credit Card

Terms and Conditions

General Membership Terms and Conditions