Flex + More

Plan Enrollment

In which market are you enrolling? *

Primary Member Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Pre-existing medical conditions *

Allergies
Asthma
Back Pain
Broken Bones
Chest Pain
COPD
Diabetes
Epilepsy/Seizure
Fainting
Headaches
Heart Conditions
High Blood Pressure
Medically Implanted Devices
Neck Pain
Open Heart Surgery
Pacemaker
Previous Spine Surgery
Recent Surgery
Tachycardia
None of the Above
Other Not Listed

Who else will be on the Flex + More Plan with you? *

Additional Flex + More Plan Members must have the same residential address as the primary member to qualify.

Second Member Name *

First

Last

Second Member Email

Second Member Phone

Second Member Pre-existing medical conditions *

Allergies
Asthma
Back Pain
Broken Bones
Chest Pain
Edema
Epilepsy/Seizure
Fainting
Headaches
Heart Conditions
High Blood Pressure
Low Blood Pressure
Medically Implanted Devices
Neck Pain
Open Heart Surgery
Pacemaker
Previous Spine Surgery
Recent Surgery
Shortness of Breath
Tachycardia
None of the Above

Additional Members

Additional family information will be enrolled when you arrive for your initial examination.

Flex Plan + More Monthly Recurring Membership *

Price: $ 125.00

I agree to annual enrollment with IMAC Regeneration Center for supportive wellness 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.

Credit Card Details *

Card

Name on Card

Signature *

Phone

Disclaimer for Flex + More Plan:

IMAC Regeneration Centers have the right to amend Flex + More plan at any time. Member will be given a 30 day written notice of any such change and has the option to cancel without penalty upon such notice.

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