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 BASIC WELLNESS 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 an 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 an initial payment, you are guaranteed a spot in the Basic Wellness Program.
• A true. team member will be in touch with you regarding scheduling your first appointment.
• You further authorize true. Women's Clinic of Grand Rapids, PC to secure payment from you with a credit card.
• You have three options of paying: (1) Pay $600 today; (2) Pay $300 today and have six (6) additional payments of $50; or (3) Pay $50 a month for 12 months.
• This agreement is a 12-month commitment and will automatically renew each year unless otherwise canceled 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.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Change fonts

• Draw Signature
  
• Type In Signature
  

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

Insert Signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Signature Certificate

Document name: Patient Basic Wellness Contract

Unique Document ID: cae1ed2a38f86db3ecf2c5358b16b89862dba42b

Build. Track. Sign Contracts.

Timestamp	Audit
February 4, 2020 2:42 pm EDT	Patient Basic Wellness Contract Uploaded by Allyn Lebster - [email protected] IP 76.192.145.156, 76.192.145.156

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