Advanced Wellness Program Agreement

Advanced Wellness Program Agreement

Fill out the form below to enroll or re-enroll in the Concierge Advanced Wellness Program at Forum Health Denver!
Overview of Benefits:
Assessments:
- Annual Physical Wellness Exam
- Evaluation of comprehensive blood work (unlimited)
- Genetic testing and counseling (if indicated or desired)
- Body fat analysis (unlimited)
- Specialized testing (stool, cardiac, allergy, urine, etc.
Recommendations:
• Forum Health provides in-depth health goals to help you achieve an optimal state of Mind, Body, and Lifestyle through a functional and integrative approach.

• Preventative health recommendations including Cardiovascular and Cancer screening

• Hormone balancing recommendations and adjustments if needed

• IV therapy and peptide recommendations

• Skin care evaluation and recommendations

• Regenerative medicine recommendations such as nutrition, supplements, or exosome therapy
Anti-Aging/Bio-Identical Hormone Therapy:
If desired by the patient, Dr. Grover and Erika Shepard FNP-C will order, review, and make recommendations for optimizing sex hormones, thyroid, adrenal, and growth hormone as indicated.
Wellness & Nutrition Coaching:
Wellness coaching appointments can be made with our nurse, Julie. This is especially helpful if you would like help with nutrition, weight loss, muscle gain, cognitive optimization, or gut health optimization.
Communication:
·      Accommodations whenever possible for same day or next business day appointments for urgent medical situations

·   Long appointments (if needed)

· 10 Annual Visits with Dr. Grover and/or Erika Shepard FNP-C (Zoom, phone, or in-person visit options)

·   Email and phone support with our office
Financial Benefits:
- Highly discounted lab pricing
- 15% off Vivace
- 15% off ALL supplements
- 15% off Ketamine Therapy
- 15% off Hormone Replacement Therapy
- 15% off ALL peptides and IV therapies
- (3) FREE Pulse Electromagnetic Frequency Therapy (PEMF) & Infrared Light Sessions
- Additional family, spouse, sibling or significant other may receive a 10% discount on their membership fee

MEMBERSHIP FEES & PAYMENT OPTIONS
Members shall pay an annual membership fee to Forum Health Denver per the schedule selected below.

You will be contacted about renewing your membership before it expires.
PLEASE CHECK DESIRED FEE SCHEDULE*

4 QUARTERLY auto-charged payments1 ANNUAL payment12 MONTHLY auto-charged payments
Payment Authorization: The Client authorizes to charge the following credit card for the yearly agreement fee of $_______ on the effective date of this agreement
Cardholder Name: ______________________________________
Card Number: _____________________________________
Expiration Date (MM/YY): ______ / ______
CVV: ______

Billing Address: ___________________________
Please call our office to change your credit card on file for autopayments. YOU CAN CHANGE THE CARD ON FILE AT ANY TIME.

EARLY TERMINATION
By checking "I agree", you understand that if you decide to terminate your annual contract before it expires, you will not be reimbursed or refunded any payments already made. If you decide to terminate your contract early, you are responsible for an early termination fee of $500. Dr. Grover will not be able to continue refills of medications beyond a 3-month grace period should this agreement be terminated.*

I agree
EMAIL OR ZOOM COMMUNICATIONS PRIVACY
By checking "I agree", you are aware that by wishing to communicate via email, phone, or Zoom with Dr. Grover, your personal health information may not be protected through a secure medium. Although Dr. Grover will take steps to keep your communications with his practice confidential and secure, the confidentiality of email communications cannot be assured or guaranteed.*

I agree
By signing below, you are consenting to any and all principles, agreements, and responsibilities stated above.*

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3400 E. Bayaud Ave, Suite 444 Denver, Co. 80209

Email: denver@forumhealth.com

Secure Fax #: 303-974-5945
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Advanced Wellness Program Agreement

Overview of Benefits:

Assessments:

Recommendations:

Anti-Aging/Bio-Identical Hormone Therapy:

Wellness & Nutrition Coaching:

Communication:

Financial Benefits:

MEMBERSHIP FEES & PAYMENT OPTIONS

EARLY TERMINATION

EMAIL OR ZOOM COMMUNICATIONS PRIVACY