FORMÉ Medical Membership Contract

FORMÉ Medical Membership Contract

For Basic, Plus & Premium Plan
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Gender

MaleFemale
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Explanation of Plan fees and charges:
Select your annual membership level:
Initial indicating you agree to the annual membership level and fee below.
Initial indicating you understand there is a One-time Registration Fee of $75.00 NON-REFUNDABLE (new members) & filing fee of $25.00 NON-REFUNDABLE (renewal for existing members) each year.
Initial indicating you understand that you will receive a bill from the Laboratory company, if additional bloodwork is performed.
The Registration Fee must be paid upon signing of this agreement. This membership has a 12-month minimum term and must be renewed in accordance with the terms of this agreement.
Payment in full for the membership must be completed within the next 30 calendar days after signing up the contract.
Cancellation policy
All cancellation requests must be submitted within 24 hours in writing to info@formezone.com for full refund, less registration fee, and less rendered services charged as compassionate fee (non-members).
Declined/Insufficient funds charge policy
By signing below, I agree that I have read and understand all terms of this agreement listed above and all my inquiries have been addressed.

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Formé in writing of any changes in my account information or termination of this authorization.

If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day.
In the case of a CHECK Transaction being rejected for Non-Sufficient Funds (NSF), I understand that Formé may at its discretion attempt to process the charge again with 30 days, and agree to an additional $35.00 charge for each attempt returned NSF which will be initiated.

I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form
NOTICE: DO NOT SIGN THIS CONTRACT UNTIL YOU HAVE READ AND UNDERSTOOD ALL OF THE INFORMATION WRITTEN IN THIS CONTRACT. CONSUMERS RIGHT TO CANCELLATION: YOU MAY CANCEL THIS CONTRACT WITHOUT ANY PENALTY OR FURTHER OBLIGATION WITHIN TWENTY FOUR HOURS (24HRS) FROM THE DATE THIS AGREEMENT IS SIGNED.
Choose Your Plan
Sign here:

Member's Signature
Write today's date:

Today's Date
Payment Authorization
My Products
prevnext( X )
BASIC PLAN NEW Annual Contract
$440.00 Quantity



BASIC PLAN RENEWAL Annual Contract
$390.00 Quantity



PLUS PLAN NEWAnnual Contract
$805.00 Quantity



PLUS PLAN RENEWALAnnual Contract
$755.00 Quantity



PREMIUM PLAN NEWAnnual Contract
$2,070.00 Quantity



PREMIUM PLAN RENEWALAnnual Contract
$2,020.00 Quantity



Total

$0.00
The payment is ready! It will be completed once you submit the form.
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FORMÉ Medical Membership Contract

Explanation of Plan fees and charges:

Cancellation policy

Declined/Insufficient funds charge policy

Payment Authorization