General 4 — Revive Health Foundation

Revive Health Foundation

A 501(C)(3) Wellness Charity

Our Mission:

We believe that wellness should not be reserved for the wealthy and that finances should never be the only barrier to experiencing comprehensive and integrative care. As such, it is our mission to expand access to high quality care for underserved populations including those with low income.

Name

First Name

Last Name

Date of Birth:

Month/Day/Year

Gender

Email

Patient Eligibility

Only patients below a certain income level are eligible for healthcare through Revive Health Foundation. Please select one of the following options for eligibility:

Other

If you selected "other" for the patient eligibility question, please explain.

Income & Family

Please state your annual household income and family size.

Attestation

By submitting this form, you are attesting that the information contained is true and accurate to the best of your knowledge.

Scheduling

Congratulations on completing your application form! Click the link below to request your initial appointment.

Once you submit your appointment request, you’ll receive an email confirmation along with an invitation to join Dr. Althaus’ Charm patient portal. Prior to your appointment, you’ll register your portal account and complete the intake paperwork for your visit.

Schedule Now

Application to Become a Patient

Revive Health Foundation

Scheduling

Revive Health Foundation