Membership AgreementMichael Golden Consulting, LLC Online Enrollment with Credit Card Payment Only "*" indicates required fields Step 1 of 4 - Initial Agreement 25% I have engaged Michael Golden Consulting, LLC(Corporation), to provide non-covered, non-clinical amenities and benefits to me for an initial period of one year beginning on {fancy_date}. I understand that this Agreement will renew automatically following the end of each one-year period unless I provide the Corporation 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 these non-covered services, amenities and benefits. As used in this Agreement, the term “Service Year” refers to the one-year period beginning on {fancy_date}, as well as every one-year renewal period thereafter.To learn more about the benefits of concierge medicine, download our Information Materials.Membership TypeIndividual ($2,250.00)Couple ($4,110.00) This Agreement is for non-covered, non-clinical amenities and benefits as described in theHighlights & Details document. I have read and understand this Agreement as well as the Highlights & Details and Frequently Asked Questions 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 the Corporation 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. If you have questions, please call our Membership Information Line: (978) 595-2400. We will be happy to assist you. 1st MemberName* First Last Date of Birth* MM slash DD slash YYYY Gender*MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?* Yes No Email* 2nd MemberName* First Last Date of Birth* MM slash DD slash YYYY Gender*MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?* Yes No Email - OPTIONAL Payment Schedule* I will pay annually. I understand that the full annual fee will be charged upon receipt of this form and the full annual fee will be charged automatically at 12-month intervals, continually while this Agreement remains in effect. I will pay semiannually. I understand that one-half of the full annual fee will be charged upon receipt of this form and one-half will be charged automatically at six-month intervals, continually while this Agreement remains in effect. I will pay quarterly. I understand that one-quarter of the full annual fee will be charged upon receipt of this form and one-quarter will be charged automatically at three-month intervals, continually while this Agreement remains in effect. Your ANNUAL Payment:This is the amount that will be charged to your card upon submission of this form, and will subsequently be charged ANNUALLY:Your SEMIANNUAL Payment:This is the amount that will be charged to your card upon submission of this form, and will subsequently be charged SEMIANNUALLY:Your QUARTERLY Payment:This is the amount that will be charged to your card upon submission of this form, and will subsequently be charged QUARTERLY:Credit Card DetailsCredit Card Type* Visa Master Card Discover Amex Card Number* Card Number* Expiration Date*Please use the format MM/YY Security Code* Security Code* Cardholder Name* Billing Address* 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*Consent* I authorize Michael Golden Consulting, LLC to automatically charge my credit card the amount(s) indicated on this form. Digital SignatureDigital Signature*Please type your initials to confirm this agreement. Is the home address different from billing address* Yes No Home Address* 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?*I am a Current PatientI am a Former PatientInsurance ProviderInternet SearchPatient ReferralPhysician ReferralPrint AdvertisingOtherEmailThis field is for validation purposes and should be left unchanged. Δ
