Longevity Wellness ePatient Portal

Proactive Wellness Centers

ePatient Portal

|

Home

Login

Create Profile

12/4/2024 3:16:44 AM | Map

Location | Program Expiration:

Linked Patient Status

Only established patients of Proactive Wellness Centers 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

User Name
Password
Re-enter Password	Password mismatched

Username should be a minimum of 6 characters and is NOT case sensitive. Passwords must be at least 8 and maximium 15 characters long and include at least one letter, and at least one number and not include any special characters. Passwords ARE case sensitive. Please choose your username carefully as you will not be able to change it after initial creation.

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.

Your request registered for billing person, please continue to filling form.

Create Link With Billing Person

Use this section if user has the billing person login credentials. Using this method the linkage is immediately effective.

Requester ID

Check this box if you want the billing person to have access to your profile and get copies of all email correspondence sent to you.

Billing Person User Name

*

Billing Person Password

*

Relationship with Billing Person

Request For Billing Person

Use this section if user does NOT have the billing person login credentials. User must have the billing person’s name and date or birth or unique patient ID to use this method.
Billing Person Name	*
Billing Person ID
	OR
Date Of Birth

Personal Information

First Name		Middle Name		Last Name
Suffix			[?]
Primary Phone Is International		Secondary Phone Is International		Billing Phone Is International
SMS Default Mobile No. :
Leave Voice Mail	[?] Content	Leave Voice Mail	[?] Content	Leave Voice Mail	[?] Content
Date of Birth		Sex	MF	SSN
Email 1		Email 2		Race
Marital Status		Time Zone
How did you hear about us		Location
DL Lic.
Do you require medically coded invoices for your visits ?

Address Information

Billing Address Line 1
Billing Address Line 2
Billing Country
Billing State
Billing City
Billing Zip Code
Use Billing Address as a 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.
Check this box for limited intake only.

Error Details

Leave this field blank.

Proactive Wellness Centers | Longevity Wellness ePatient Portal

Login Footer

PMD-WEB4

Alert

Alert

Alert