Join the Maxem Health Discount Program

Join the Maxem Health Discount Program
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
How did you hear about us?

Additional Details
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Member Info
Date of Birth*

MonthDayYear
Gender*
Preferred Language*
Emergency Contact
Name*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Email
example@example.com

Discount Program Plans*

IndividualFee Includes: Setup & Co-Pay for First Visit | Co-Pay: $60/per visit per person

$175.00

Family of TwoFee Includes: Setup & Co-Pay for First Visit | Co-Pay: $75/per visit per person

$250.00

Family of FourFee Includes: Setup & Co-Pay for First Visit | Co-Pay: $100/per visit per person

$450.00

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty: