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. Once submitted, a member of our team will review your responses and reach out within 24–48 hours to discuss next steps.

First name

Last name

Email

Phone

Birthday

Month

Day

Year

State of Residence

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

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

Do you currently have an active cancer diagnosis?

Yes

No

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

Please provide your past medical history.

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

Do you have any known allergies?

Yes

No

If "Yes," please specify:

What medications are you currently taking?

Are you currently seeing any other healthcare providers?

Yes

No

If "Yes," please list their specialties:

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

Yes

No

If "Yes," please describe your experience:

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

Very Committed

Somewhat Committed

Not Committed

Which membership option would you like to move forward with?

Thrive - $20,000

Nurture - $6,800

Foundations - $3,800

Wellness Review & Strategy Call (A one time personalized session) - $2,000

(Please keep in mind, if you are interested in HRT, thyroid optimization, or testosterone, you must be on Nurture or Thrive)

Please select your preferred payment plan

Annual (One-time)

Quarterly

Is there anything else you would like us to know about your health or wellness goals?