Start Your Wellness Journey with Rever Wellness

Thank you for your interest in joining Rever Wellness! Please fill out the following questionnaire to help us understand your health needs and determine if our services are a good fit for you.

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Full Name *
Date of Birth *
Email Address  *
Phone Number *
State of Residence

We are currently licensed to see patients in the following states: FL, CA, NY, MA, DC, IL, WA, IA, VT, VA, NM, UT, WY, DE, CO, KS, OR
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How did you hear about us? *

What brings you to apply for our functional health and hormone optimization services?

(Please provide a brief description of your health goals or concerns.)

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If I could wave a magic wand and three things could happen as a result of our work together, what would those three things be?

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Do you currently have an active cancer diagnosis?

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Note: If you answered "Yes," we can support you after you are in remission, but at this time, we cannot prescribe peptides or hormones.

If you wish to have a diagnosis or prescription, you will need to establish care in Florida.

Please provide your past medical history.

(Include any significant illnesses, surgeries, or conditions.)

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Do you have any known allergies?

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If "Yes," please specify:

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What medications are you currently taking?

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Are you currently seeing any other healthcare providers?

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If "Yes," please list their specialties:

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Have you previously engaged in any functional medicine or holistic health practices?

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If "Yes," please describe your experience:

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 How committed are you to making lifestyle changes for your health?

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Which membership option would you like to move forward with? 

(Please keep in mind, if you are interested in HRT, thyroid optimization, or testosterone, you must be on Nurture or Thrive)
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 Is there anything else you would like us to know about your health or wellness goals?

Thank you for taking the time to complete this questionnaire. We will review your responses and get back to you shortly. Your health journey is important to us, and we look forward to supporting you!
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