Dear Valued Member,

If you have recently experienced a physical injury resulting in serious physical dissability, please fill out this online information form and you will receive our official PDF PHYSICIANS FORM via email  for you to print out and have your Physican complete, sign and send the signed form to us at pay@southbeachactive.com .  

Member's First Name	*
Member's Last Name	*
Member's Email	*
Physicians Name	*
Physicians Ph Number	*
Comments:
Security Code	*