Create Profile 3/3/2026 12:01:12 PM | Map Location | Program Expiration:
Create New Patient
Only established patients of Proactive Wellness Centers PLLC and future patients who are ready to begin the intake process should create an account. This will establish you as an online user and allow you to enter and update your profile, make online appointments, purchase supplements and medications from our online store and download our intake forms.

Login Information

Username should be a minimum of 6 characters and is NOT case sensitive. Passwords must be at least 8 characters long and include at least 1 uppercase letter, 1 lowercase letter, 1 number, and 1 special character (e.g., ! @ # $ % ^ & *). Passwords ARE case sensitive. Please choose your username carefully as you will not be able to change it after initial creation.

User Name
Password
Re-enter Password

Billing Person Administration

If someone other than patient will be financially responsible (Billng Person), click the button below. Before clicking this button, note that the Billing Person must have previously completed this registration page. If you have any questions about using the Billing Person capability, please contact the office that you are registering with.

Personal Information

First Name
Middle Name
Last Name
Suffix
Use Email
Content
Primary Phone
Leave Voice Mail
Content
Secondary Phone
Leave Voice Mail
Content
Billing Phone
Leave Voice Mail
Content
Date of Birth
Sex
SSN
Email 1
Email 2
Race
Marital Status
DL Lic.
How did you hear about us
Time Zone
Location

Address Information

Billing Address

Billing Address Line 1
Billing Address Line 2
Billing Country
Billing State
Billing City
Billing Zip Code

Shipping Address

Shipping Address line 1
Shipping Address line 2
Shipping Country
Shipping State
Shipping City
Shipping Zip Code
Note: If you are registering for Aesthetics Services only, please check the box below and the online intake will skip the medical questionnaire and related forms. If you are intending to be a hormone replacement or functional medicine patient, do NOT select this option as these forms are required. Only patients seeking aesthetics services only should check the box for the limited intake.
Proactive Wellness Centers PLLC | Proactive ePatient Portal
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