Regen Plan Enrollment

In which market are you enrolling? *

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Pre-existing medical conditions *

Regen Plan Monthly Recurring Membership *

Price: $ 300.00

I agree to annual enrollment with IMAC Regeneration Center for care described above. I acknowledge and understand that my agreement to the fees listed is based on annual assessment of pricing. My annual fee is non-refundable and is not dependent on cancellation of any or all services. Annual Membership Fee will be due at time of initial examination. I understand that the Regen Plan requires twelve (12) monthly payments and is non-refundable and cannot be cancelled at any time for any reason. If I receive services under this plan, I understand that failure to pay the monthly fee may impact my credit rating with TransUnion, Equifax, Experian, and/or any other credit rating bureau. This agreement is not an extension of credit based on credit worthiness nor is it a gurantee of results.

Credit Card Details *

Card

Name on Card

Signature *

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