Membership Agreement Vitality Medical and Wellness Consulting LLC Step 1 of 6 - Agreement 16% 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 September 26, 2023. 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 September 26, 2023 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 $2,500/year = Individual $4,925/year = Couple $1,200/year = Dependent children ages 18 to 26 when parent is a member Individual Concierge Member(s)0123456Dependent(s)01234567HiddenTotal 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. 1st Individual Concierge MemberName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Email(Required) 2nd Individual Concierge MemberName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Email(Required) 3rd Individual Concierge MemberName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Email(Required) 4th Individual Concierge MemberName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Email(Required) 5th Individual Concierge MemberName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Email(Required) 6th Individual Concierge MemberName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Email(Required) 1st Individual Concierge PLUS MemberName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Email(Required) 2nd Individual Concierge PLUS MemberName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Email(Required) 3rd Individual Concierge PLUS MemberName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Email(Required) 4th Individual Concierge PLUS MemberName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Email(Required) 5th Individual Concierge PLUS MemberName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Email(Required) 6th Individual Concierge PLUS MemberName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Email(Required) 1st DependentName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Email(Required) 2nd DependentName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Email(Required) 3rd DependentName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Email(Required) 4th DependentName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Email(Required) 5th DependentName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Email(Required) 6th DependentName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Email(Required) 7th DependentName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Email(Required) 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 DetailsCredit Card Type(Required) Visa Master Card AMEX Discover Card Number(Required) Card Number(Required) Expiration Date(Required) Security Code(Required) Security Code(Required) Cardholder Name(Required) Billing Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code How did you hear about our practice?(Required)I am a Current PatientI am a Former PatientInsurance ProviderInternet SearchPatient ReferralPhysician ReferralPrint AdvertisingOther Δ
