Flex + More Enrollment Please enable JavaScript in your browser to complete this form.In which market are you enrolling? *ChesterfieldSpringfieldNorth SpringfieldOzarkWebster GrovesPrimary Member Name *FirstLastEmail *Phone *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeWho else will be on the Flex + More Plan with you? *Spouse/Significant OtherChildParentAdditional Flex + More Plan Members must have the same residential address as the primary member to qualify.Second Member Name *FirstLastSecond Member EmailSecond Member PhoneAdditional MembersAdditional family information will be enrolled when you arrive for your initial examination. Flex Plan + More Monthly Recurring Membership *Price: $ 125.00I 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 *CardName on CardEmailSign Me Up!
