Membership Agreement

Vitality Medical and Wellness Consulting LLC

My practice is currently full, please call my membership information line (314.806.0440)

for enrollment & waitlist information.

Step 1 of 6 - Agreement

I have engaged Vitality Medical and Wellness Consulting LLC (“VitalityMWC”), to provide non-covered, non-clinical amenities and benefits to me for an initial period of one year beginning on August 17, 2022. I understand that this Agreement will renew automatically following the end of each one-year period unless I provide VitalityMWC with a written notice of non-renewal at least 30 days before the end of a renewal year. I further understand that I will be required to pay a yearly membership fee at the start of each renewal term for the non-covered services, amenities and benefits. As used in this Agreement, the term “Service Year” refers to the one-year period beginning on August 17, 2022 as well as every one-year renewal period thereafter.

To learn more about the benefits of concierge medicine as well as the differences between our Concierge and Concierge PLUS programs, download our Information Materials.

FOR PATIENT MEMBERSHIP DURING THE SERVICE YEAR, I AGREE TO PAY Vitality Medical and Wellness Consulting LLC:

Quarterly or Semi-annual Payments

$2,450/year = Individual
$4,410/year = Couple
$1,200/year = Dependent children ages 18 to 26 when parent is a member

Individual Concierge Member(s)

Dependent(s)

Hidden

Total members

(will be hidden, for logic only)

This Agreement is for non-covered, non-clinical amenities and benefits as described in the Highlights & Details (H&D) document. I have read and understand this Agreement as well as the Highlights & Details (H&D) and Frequently Asked Questions (FAQ) documents that are considered a part of this Agreement. I understand that this Agreement can be terminated upon 30 days’ written notice and that, if the Agreement is terminated, I will receive a prorated refund of the annual fee I paid, based on the number of days that have elapsed in the Service Year (which will be determined by VitalityMWC on a case-by-case basis). Such refund will be paid to me within 30 days after termination. Unless the Agreement is terminated as provided in the first paragraph of this Agreement above, it will automatically renew for subsequent Service Years under the same payment terms, unless I notify the practice otherwise (or the practice notifies me) within 30 days of the next payment due date.

Payment Schedule(Required)

charged to your card or pulled from your bank account

I will pay annually. I understand that the full annual fee will be charged to your card or pulled from your bank account upon receipt of this form and automatically at 12-month intervals, continually while this Agreement remains in effect.

I will pay semiannually. I understand one-half of the annual fee will be charged to your card or pulled from your bank account upon receipt of this form and automatically at six-month intervals, continually while this Agreement remains in effect.

I will pay quarterly. I understand one-quarter of the annual fee will be charged to your card or pulled from your bank account upon receipt of this form and automatically at three-month intervals, continually while this Agreement remains in effect.

Individual Concierge

Price: $0.00

Dependent Concierge

Price: $0.00

Couples Discount

Price: -$490.00

Your ANNUAL Payment:

This is the amount that will be charged to your card or pulled from your bank account upon submission of this form, and will subsequently be charged/pulled ANNUALLY:

Your SEMIANNUAL Payment:
This is the amount that will be charged to your card or pulled from your bank account upon submission of this form, and will subsequently be charged/pulled SEMIANNUALLY:

Your QUARTERLY Payment:
This is the amount that will be charged to your card or pulled from your bank account upon submission of this form, and will subsequently be charged/pulled QUARTERLY:

Payment via ACH has been temporarily disabled

Credit Card Details

Credit Card Type(Required)

Visa

Master Card

AMEX

Discover

Card Number(Required)

Expiration Date(Required)

Security Code(Required)

Cardholder Name(Required)

Billing Address(Required)
Street Address Address Line 2 City State ZIP Code

Daytime Phone Number(Required)

Consent(Required)
I authorize Vitality Medical and Wellness Consulting LLC (“VitalityMWC”) to automatically charge my credit card the amount(s) indicated on this form.

Digital Signature(Required)
Please type your initials to confirm this agreement.

Is the home address different from billing address(Required)

Yes

No
Home Address(Required)
Street Address Address Line 2 City State ZIP Code

How did you hear about our practice?(Required)

New Member Inquiries:
314.806.0440

Current Member Patients: 314.695.8525

Membership Agreement

1st Individual Concierge Member

2nd Individual Concierge Member

3rd Individual Concierge Member

4th Individual Concierge Member

5th Individual Concierge Member

6th Individual Concierge Member

1st Individual Concierge PLUS Member

2nd Individual Concierge PLUS Member

3rd Individual Concierge PLUS Member

4th Individual Concierge PLUS Member

5th Individual Concierge PLUS Member

6th Individual Concierge PLUS Member

1st Dependent

2nd Dependent

3rd Dependent

4th Dependent

5th Dependent

6th Dependent

7th Dependent

Credit Card Details