Membership Change Form

Did you know you can log into your Patient Portal and cancel your Membership yourself? No need to submit this form it’s super easy, just click on RETURNING PATIENT PORTAL now!

First Name

Last Name

Phone

Request Type

Membership Agreement Reminders (please check that you understand)

Memberships have a 3 month initial commitment Cancellations will void any unused vouchers on your account Credits, transfers or cash back are not applicable All additional Member Perks are forfeited Freezes are allowed once a year for a 2 month period Member perks are paused during a freeze, you may. only use your vouchers accrued! Requests must be received by the 25th for the following month effective cancel

Comments