Membership Cancellation Notice
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Email Address
*
example@example.com
Reason for cancellation
*
Cost or financial reasons
Moving to another provider
No longer need the service
Health needs have changed
Not seeing the results I hoped for
Time commitment
Other
*
I understand that submitting this cancellation request does not immediately terminate my membership. My membership will remain active through the remainder of my current 28-day Billing Cycle and for three (3) additional full 28-day Billing Cycles. I understand that I will be charged three (3) additional membership payments, each occurring every 28 days in accordance with the Payment Terms, after submitting my cancellation request. My membership will terminate at the end of the third additional Billing Cycle.
*
I understand that I will be provided with a 90 day supply of medications and that the Aurelia support team will ensure I have an off boarding call scheduled with my clinical team.
Is there anything you would like us to know?
What happens next
Your membership and care stay active through your current Billing Cycle plus three (3) additional 28-day Billing Cycles
Billing continues on your normal schedule through the notice period.
Our team will email you to confirm your final payment date.
Your clinical team will schedule an offboarding call with you before your final date to ensure you have an Rx plan in place.
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