Membership Application and Agreement

Thank you for your interest in joining the true. Women’s Clinic of Grand Rapids, PC.  This Membership Application and Agreement describes the terms of your membership in our CONCIERGE program.

*By providing your personal (not shared) email address you consent and acknowledge that we may contact you via unencrypted email and that you acknowledge and agree that we may disclose personal health information (PHI) to you in encrypted email.

By signing below (electronic or otherwise) you agree to the following:

• Women’s Clinic of Grand Rapids has limited availability and completion of your Membership Application does not guarantee enrollment.
• true. Women’s Clinic of Grand Rapids has limited availability. By signing up today and making a $2400 payment, you are guaranteed a spot in the Concierge Program.
• A true. team member will be in touch with you regarding scheduling your first appointment beginning mid-April.
• You further authorize true. Women’s Clinic of Grand Rapids, PC to secure payment from you with a credit card in amount of $2,400.00.
• Additionally you have the option of paying $1,200.00 today with two subsequent payments 90 days apart of $600 for a total of $2,400.00.
• This agreement will automatically renew each year unless otherwise cancelled by you.
• You agree to the terms of the Membership Application and Agreement and attached Terms and Conditions.

If you have provided us with an email address, buy signing below, you acknowledge and accept the risk of sending or receiving your PHI via unencrypted email, including but not limited to unauthorized access during transit and agree to not hold true. Women’s Clinic of Grand Rapids, PC and true. Women’s Health, LLC or any of its affiliates, employees or agents liable for any damages you may incur as a result of the transmittal of your PHI via unencrypted email and any breach that may occur during transit.

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Signature Certificate

Document name: Patient Concierge Contract

Unique Document ID: a04df30e9b6695f73dcbf166ddae89121eaa389b

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Timestamp	Audit
February 4, 2020 2:49 pm EDT	Patient Concierge Contract Uploaded by Allyn Lebster - [email protected] IP 2601:407:c780:6d60:8c10:b478:b881:da76, 2601:407:c780:6d60:8c10:b478:b881:da76

This audit trail report provides a detailed record of the online activity and events recorded for this document.

http://truewomenshealth.com/

Audit Trail Serial# c5c50145bf00e2240adaeedbd2279b48