Patient Agreement John Cary, MD Online Enrollment with Credit Card Payment Only Step 1 of 5 20% I have engaged John F Cary, MD, Personal Medicine PC (Corporation), to provide non-covered, non-clinical amenities and benefits to me for an initial period of one year beginning on September 15, 2020. I understand that this Agreement will renew automatically following the end of each one-year period unless I provide Corporation with a written notice of non-renewal at least 30 days before the end of a renewal year. I further understand that I will be required to pay a yearly membership fee at the start of each renewal term for these non-covered services, amenities and benefits. As used in this Agreement, the term "Service Year" refers to the one-year period beginning on September 15, 2020, as well as every one-year renewal period thereafter.FOR PATIENT MEMBERSHIP DURING THE SERVICE YEAR, I AGREE TO PAY CORPORATION:*Dependent children 18 up to age 26 included when parent is a member. $1,800/year = Individual (payable annually, semiannually, or quarterly) $3,240/year = Couple (payable annually, semiannually, or quarterly) NUMBER OF DEPENDENTS (Children 18 up to age 26) - OPTIONALPlease select number of dependent children (OPTIONAL)One (1) Dependent Child (18 up to age 26)Two (2) Dependent Children (18 up to age 26)Three (3) Dependent Children (18 up to age 26)Four (4) Dependent Children (18 up to age 26)Five (5) Dependent Children (18 up to age 26)This Agreement is for non-covered, non-clinical amenities and benefits as described in the Highlights & Details document. I have read and understand this Agreement as well as the Highlights & Details and Frequently Asked Questions documents that are considered a part of this Agreement. I understand that this Agreement can be terminated upon 30 days' written notice and that, if the Agreement is terminated, I will receive a prorated refund of the annual fee I paid, based on the number of days that have elapsed in the Service Year (which will be determined by the Corporation on a case-by-case basis). Such refund will be paid to me within 30 days after termination. Unless the Agreement is terminated as provided in the first paragraph of this Agreement above, it will automatically renew for subsequent Service Years under the same payment terms unless I notify the practice otherwise (or the practice notifies me) within 30 days of the next payment due date.Patient #1Name (Patient #1)* First Last Email (Patient #1)* Daytime or Mobile Phone Number (Patient #1)*Date of Birth (Patient #1)* MM slash DD slash YYYY Gender (Patient #1)* Male Female Is Patient #1's home address different than the billing address?* Yes No Home Address (Patient #1 - if different from billing address)* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Digital Signature (Patient #1)*Please type your initials to confirm this agreement.Patient #2Name (Patient #2)* First Last Email (Patient #2) - OPTIONAL Daytime or Mobile Phone Number (Patient #2)*Date of Birth (Patient #2)* MM slash DD slash YYYY Gender (Patient #2)* Male Female Is Patient #2's home address different than the billing address?* Yes No Home Address (Patient #2 - if different from billing address)* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Digital Signature (Patient #2)*Please type your initials to confirm this agreement. Dependents:Dependent #1Name (Dependent #1)* First Last Date of Birth (Dependent #1)* MM slash DD slash YYYY Gender (Dependent #1)* Male Female Email (Dependent #1) - OPTIONAL Dependent #2Name (Dependent #2)* First Last Date of Birth (Dependent #2)* MM slash DD slash YYYY Gender (Dependent #2)* Male Female Email (Dependent #2) - OPTIONAL Dependent #3Name (Dependent #3)* First Last Date of Birth (Dependent #3)* MM slash DD slash YYYY Gender (Dependent #3)* Male Female Email (Dependent #3) - OPTIONAL Dependent #4Name (Dependent #4)* First Last Date of Birth (Dependent #4)* MM slash DD slash YYYY Gender (Dependent #4)* Male Female Email (Dependent #4) - OPTIONAL Dependent #5Name (Dependent #5)* First Last Date of Birth (Dependent #5)* MM slash DD slash YYYY Gender (Dependent #5)* Male Female Email (Dependent #5) - OPTIONAL Payment Schedule* I will pay annually. I understand that the full annual fee will be charged upon receipt of this form and the full annual fee will be charged automatically at 12-month intervals, continually (beginning September 15, 2021) while this Agreement remains in effect. I will pay semiannually. I understand one-half of the annual fee will be charged upon receipt of this form and one-half will be charged automatically at six-month intervals, continually (beginning March 15, 2021) while this Agreement remains in effect. I will pay quarterly. I understand one-quarter of the annual fee will be charged upon receipt of this form and one-quarter will be charged automatically at three-month intervals, continually (beginning December 15, 2020) while this Agreement remains in effect. Consent* I authorize Corporation to automatically charge my credit card the amount(s) indicated above Credit Card Type* VISA MasterCard AMEX Discover Card Number*Card Number*Expiration Date*Security Code*Security Code*Cardholder Name*Billing Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Daytime Phone Number*How did you hear about our practice?*I Am a Current PatientI Am a Former PatientInsurance ProviderInternet SearchPatient ReferralPhysician ReferralPrint AdvertisingOtherCAPTCHA Δ
