The Revive Membership Enrollment

Medical Disclosure:

By enrolling in the Revive-ify Membership, I acknowledge that Revivify Wellness and its licensed providers offer telemedicine-based medical services focused on wellness, medical weight management, and related therapies. I understand that treatment plans may include prescription medications (including compounded or brand-name options), supplements, or peptides, when medically appropriate.

 

I understand that:

1. Services are not a substitute for in-person medical care or emergency treatment.

2. My provider may require recent labs or additional health information before prescribing medications.

3. Results are individual and cannot be guaranteed.

4. I am responsible for informing my provider of any changes in my medical history, medications, or health status.

 

Telehealth Consent:

I consent to receive medical care via telehealth, meaning I may be evaluated and treated through electronic communications. I understand the potential risks and limitations of telemedicine, and I agree to proceed with care in this format.

 

HIPAA & Privacy Consent:

I acknowledge that Revivify Wellness follows all federal and state laws governing the privacy and security of my health information (HIPAA). My personal health information will only be used for purposes of treatment, billing, and clinic operations. My information will not be shared without my written consent, except as required by law.

 

Membership & Billing Consent:

By submitting this form, I authorize Revivify Wellness and its payment processor (Stripe) to securely store my payment method and charge the monthly membership fee as outlined in the membership description. I understand that this membership renews automatically each month until I provide written notice of cancellation.

The Revive Membership is a monthly wellness program designed to provide ongoing, personalized support to help you look, feel, and function your best. By enrolling, you receive the following benefits:

What’s Included

Initial medical consultation — $150 (one-time)
Ongoing membership — $99/month
15% savings on all GLP-1 medications and peptide therapies
Access to Revive-ify specials, including bundled peptide pricing
Continuous medical support throughout your wellness journeyUnlimited messaging access with your provider via the partient portal for:

• Progress check-ins
• Dosing adjustments
• Questions about symptoms or side effects
• Accountability and ongoing support
• Guidance on nutrition, supplements, exercise, and lifestyle optimization
• Optional monthly follow-up visit (scheduled as needed)

This membership enhances your access, support, and savings — and is not insurance or a replacement for primary care or emergency services.

 

Billing & Renewal

Your membership will be billed at $99/month (not including CC fees)
Billing renews automatically each month through the payment method you provide
Medication and peptide costs are billed separately as ordered

Cancellation Policy (30-Day Notice Required)

You may cancel your membership at any time by providing 30 days written notice.

To cancel, you must email:
📧 myrevivifywellness@gmail.com

Please note:

All payments due within the 30-day notice period will still be charged
Membership fees are non-refundable, including partial months
All membership benefits (discounts, messaging access, follow-up access) end once the 30-day cancellation period is complete