Welcome to Revive Proactive Health!

- Please print & fill out the form's below completely.

- After filling them out, sign, scan and email back to

- A member of our staff will reach out to you within 48 hours of receiving your completed forms.

- Thank you.

Medical Release Form

Medical History Form

Payment Authorization Form


All of your information is kept 100% confidential and its sole use is for our staff to better assist you.