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WECARE MEDICAL MEMBERSHIP $100/ Nonrefundable applicationFee

$50/mo per person

Automatic monthly payments with 6 months minimum required

Includes:

Unlimited 15-minute visits

Free follow ups

Small copay for test/treatments

Level 1($15)

Level 2 ($25)

Level 3 ($35)

Level 4 ($45)

Same Day Appointments Available Online

WECARE MEDICAL MEMBERSHIP

Application fee $100 per person

Monthly Price $50.00 per person

MEDICAL MEMBERSHIP AGREEMENT:

I agree to purchase the MEDICAL MEMBERSHIP with FNP & Associates, PLLC dba EasyCare Health and Wellness Clinic. 

I am aware this MEDICAL MEMBERSHIP requires automatic monthly payments through Square or our preferred POS or automatic banking system, first payment will include $100 application fee per person and the first $50.00 monthly fee, and then 50.00 will be paid every 1st day of each month following for the purchase of this MEDICAL MEMBERSHIP. 

I am aware that I can cancel my MEDICAL MEMBERSHIP after 6 months. I will then receive product and services at regular price for any and all included features or discounts offered with the MEDICAL MEMBERSHIP, as it will no longer apply to me for such services. Cancellation may take 5-7 days to process. 

I am authorizing FNP & Associates, PLLC and it’s dba to process an automatic payment withdraw using my credit card or bank account to pay for the listed monthly membership fee per the price of $50.00 a month.

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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