First Name

Last Name

Phone *

Please use a unique phone not already registered in our system (if you're already a patient, simply text 813-499-0037 with your question or request. Thank you!)

Email *

Please use a unique email not already registered in our system (if you're already a patient, simply email [email protected] with your question or request. Thank you!)

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Electronic Records and Consent to Treat

I agree to use electronic records and signature, by clicking this box, I acknowledge that I have read the related consumer disclosure, terms of service, privacy policy, notice of privacy practices and agree to discuss my medical history, treatment including but not limited to risks, benefits and alternatives.

By submitting this form, you agree to receive SMS and email communication from Active Management Solutions, d/b/a Active Medical Solutions, and its affiliated companies under Active Group Holdings, including Active Life Coaching LLC. You may revoke consent at any time and in any reasonable manner, including by texting STOP. Message and data rates may apply.

I agree to the Terms of Service, Privacy Policy, and Consumer Disclosures. By providing my phone number, I agree to receive text messages from the business.