New Patient Signup

the following form begins the signup process! Before filling out this form, you should have thoroughly read the information presented under the "Services" and "Getting Started" menu tabs of our website to ensure we are the right choice for your treatment needs. The "Services" drop-down menu items will guide you through the healthcare services we offer, and the "Getting Started" drop-down menu items will guide you through our insurance statement, what to expect when you become a patient, your appointment frequency, and cost estimates. once you are ready to become a patient, please fill out the form below and we will respond to you within 72 hours after receiving this form submission.

First Name*

Middle Name (not initial)*

Last Name*

Street Address*

City*

State*

Zip Code*

Phone (xxx-xxx-xxxx)*

Email*

Date of Birth (mm/dd/yyyy)*

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Alive and Well Health

501 Long Hollow Pike, Suite A, Goodlettsville, TN 37072

Phone: (615) 732-2020 Fax: (615) 732-2030 Email: office@aliveandwellhealth.com