Membership Agreement Inner Balance Integrative Medicine Membership Agreement Form Step 1 of 6 – Agreement 16% I have engaged John Bordiuk Consulting LLC (Company) and its physician John Bordiuk, MD to provide non-covered, non-clinical amenities and benefits to me for an initial period of one year beginning on December 23, 2024. I understand that this Agreement will renew automatically following the end of each one-year period unless I provide the Company with a written notice of non-renewal at least 30 days before the end of a Service 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 December 23, 2024, as well as every one-year renewal period thereafter. $3,000/year = Individual $5,400/year = Couple $500/year = Each dependent child (between the ages of 18 and 26 years old) of an enrolled member Individuals (26 and over)0123Dependent child (ages 18 up to 26 years old) of an enrolled member01234567HiddenTotal members(will be hidden, for logic only)Individuals (26 and over) Price: $0.00 Couples DiscountApplied for the first additional adult over the age of 26. Price: $0.00 Dependent child (ages 18 up to 26 years old) Price: $0.00 Total 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 may 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 Company 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 Company otherwise (or the Company notifies me) within 30 days prior to the next payment due date. 1st Individual (26 and over)Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone Number(Required)Is this a cell number?(Required) Yes No Cell Phone Number(Required)Email(Required) 2nd Individual (26 and over)Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone Number(Required)Is this a cell number?(Required) Yes No Cell Phone Number(Required)Email(Required) 3rd Individual (26 and over)Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone Number(Required)Is this a cell number?(Required) Yes No Cell Phone Number(Required)Email(Required) 1st Individual (ages 18 up to 26 years old)Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Cell Phone NumberEmail 2nd Individual (ages 18 up to 26 years old)Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Cell Phone NumberEmail 3rd Individual (ages 18 up to 26 years old)Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Cell Phone NumberEmail 4th Individual (ages 18 up to 26 years old)Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Cell Phone NumberEmail 5th Individual (ages 18 up to 26 years old)Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Cell Phone NumberEmail 6th Individual (ages 18 up to 26 years old)Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Cell Phone NumberEmail 7th Individual (ages 18 up to 26 years old)Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Cell Phone NumberEmail Payment Schedule(Required) I will pay annually I will pay semianually I will pay quarterly 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 while this Agreement remains in effect.I understand that one-half of the full annual fee will be charged upon receipt of this form and and one-half will be charged automatically at six-month intervals, continually while this Agreement remains in effect.I understand that one-quarter of the full annual fee will be charged upon receipt of this form and and one-quarter will be charged automatically at three-month intervals, continually while this Agreement remains in effect.Your ANNUAL Payment:This is the amount that will be charged to your card upon submission of this form, and will subsequently be charged ANNUALLY:Your SEMIANNUAL Payment:This is the amount that will be charged to your card upon submission of this form, and will subsequently be charged SEMIANNUALLY:Your QUARTERLY Payment:This is the amount that will be charged to your card upon submission of this form, and will subsequently be charged QUARTERLY:HiddenPayment Methodcredit cardACHCredit Card DetailsYour card will be charged by John Bordiuk Consulting LLC Credit Card Type(Required) Visa MasterCard AMEX Discover Card Number(Required) Card Number(Required) Expiration MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberExpiration Year2023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050Security Code(Required) Security Code(Required) Cardholder Name(Required) Billing Address(Required) 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(Required)Consent(Required) I authorize John Bordiuk Consulting LLC to automatically charge my credit card the amount(s) indicated on this form. ACH OptionBilling Address(Required) 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(Required)Bank Name(Required) Account TypeBusinessPersonalRouting Number(Required) Please Confirm Your Routing Number(Required) Account Number(Required) Please Confirm Your Account Number(Required) Consent(Required) I authorize John Bordiuk Consulting LLC to automatically pull from my bank account the amount(s) indicated on this form. Digital Signature(Required)Please type your initials to confirm this agreement. Is the home address different from billing address(Required) Yes No Home Address(Required) 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 How did you hear about our practice?(Required)I am a Current PatientI am a Former PatientInsurance ProviderInternet SearchPatient ReferralPhysician ReferralPrint AdvertisingOtherPlease elaborate(Required)
